Respiratory Flashcards
Pneumonectomy/Lobectomy
Thoracotomy scar
Trachea shifted to the same side of the pneumonectomy/lobectomy or may be central if lower lobectomy
Flattening of the chest on the same side and reduced respiratory movements
Dull to percussion
Reduced or absent breath sounds (if pneumonectomy), bronchial breathing in upper zone
To complete my examination:
Vitals specifically SpO2
ABG +/-
Investigations:
Blood tests
- routine labs including autoimmune screening, blood cultures, sputum cultures
Imaging
- CXR, CT Chest
Etiology:
1. Bronchiectasis from previous TB infection
2. Lung cancer
3. Lung abscess
4. Previous episode of hemoptysis which proved refractory to initial therapy with bronchial artery embolisation
Tests for suitability for lobectomy/pneumonectomy
Spirometry
- if FEV1 >1.5L for lobectomy, if FEV1 >2L for pneumonectomy
Exercise testing for any desaturation
Bronchiectasis
Cachectic, respiratory distressed, cyanosis clubbing
May have CO2 retention flap with a bounding pulse
Look at eyes for partial ptosis, meiosis,anhydrosis (Horner’s syndrome in Pancoast tumour)
JVP elevated in right heart failure
Auscultation:
- coarse inspiratory crepitations which change on character with coughing
To complete my examination:
- vitals checking SpO2, any evidence of fever
Investigations:
Blood tests to look for signs of infection including autoimmune screening to see if CTD cause
ECG- any signs of right ventricular strain/hypertrophy
Imaging:
CXR- tram lines, dilated thickened airways
HRCT- signet ring sign
Lung function tests
Etiology:
1. Post infectious
- TB, measles, pertussis
2. Obstructive
- chronic aspiration, lung tumour, COPD
3. Muco-ciliary defects
- Cystic fibrosis, kartgeners syndrome
4. CTD
- RA, SLE, Sjogrens
5. Yellow nail syndrome
- bronchiectasis, bilateral pleural effusions, lymphedema, yellow nails
Management:
Life style
- patient education, smoking cessation, reducing occupational exposure to inhalants risk
- MDT approach referral to physiotherapy for pulmonary rehabilitation
Medical
- Bronchodilators if co-existent COPD
- screening for infective exacerbation and treat
- Vaccination- yearly for haemophilia and influenza, pneumococcal every 2-3 years
Surgical
Lobectomy for localised bronchiectasis
Lung transplantation in CF
Pulmonary Fibrosis
Cyanosis- on LTOT, plethora (Polycythaemia), Cushingnoid
Clubbing, peripheral cyanosis look for CTD , may have CO2 retention
JVP right heart failure
Reduced chest expansion bilaterally
Percussion may be dull at the base
If IPD_ velcro like crepitations which does not clear after coughing
To complete my examination:
- check vitals
- obtain a detailed history mainly looking at drug history, occupation history, smoking history
- MSK examination
- ECG to look for right heart strain
Investigations:
Blood tests- routine labs, autoimmune screening look for CTD
Imaging
CXR
HRCT- GGO of the lung parenchyma and in later stages reticular abnormalities with honeycombing
Other tests:
Spirometry to assess severity of disease
- expect a restrictive pattern FEV1/FVC >0.7
- ABG type 1 RF LTOT if pO2 <55mmHg
Look for complications of the disease
- Pulmonary HTN (ECHO)
- Polycythaemia- FBC
Etiology:
1. IPF
2. CTD
- RA, SS, AS, psoriasis, MCTD,
3. Drugs
- Amiodarone, antibiotics- nitrofuroantion, methotrexate, cytotoxic bleomycin
4. Occupation
- Coal workers, silicosis, asbestosis
5. Vasculitis
- Wegeners and Churg Strauss
6. Infection
- TB, aspergillosis
Management:
Lifestyle
- Patient educations, smoking cessation, occupational
- Refer for pulmonary rehabilitation, MDT approach
Medical
- Antibiotic for acute infection
- LTOT if PaO2 <55mmHg
- Immunosuppression depending on the underlying cause
- Consider pirfenidone in IPF
Surgical
- Lung transplantation in advanced disease
Causes of apical fibrosis
BREAST
Bronchopulmonary aspergillosis
Radiotherapy
Extrinsic allergic alveolitis
Ankylosing spondylitis/psoriatic arthritis
Silicosis
TB
Causes of lower lobe fibrosis
DAM IRS
Drugs
Asbestosis
Mixed connective tissue disease
IPF
RA
SS
Pleural effusion
Tracheal deviation away if massive
Reduced chest expansion
Stony dull percussion
Reduced AE
Reduced vocal resonance
To complete my examination:
- vitals
- sputum pot
- taking a detailed history: constitutional symptoms, fever, cough
The findings are in keeping with a pleural effusion
Investigations:
Bloods- infection
Imaging
CXR- PA, consider lateral decubitus in small effusion
U/S guided thoracocentesis to differentiate transudate or exudate using Lights criteria
- if pleural fluid protein to serum protein ratio >0.5
- pH <7.2 parapneumonic effusion
- send for cultures, AFB, cytology
CT chest
Etiology:
Exudative
1. Infection- TB, parapneumonic, empyema
2. Neoplastic- lung Ca
3. Inflammatory- SLE, RA, Sarcoidosis
4. Drugs- methotrexate
Transudative
Heart failure, nephrotic syndrome, CLD, hypothyroidism
Management:
MDT
- oxygen, chest physiotherapy
- therapeutic chest drainage
Surgical
- surgical decortication for empyema
- if recurrent VATS
What is VATS procedure and its indications?
Video assisted thorascopic surgery
Indications:
- bullectomy and lung volume reduction surgery in emphysema
- correction of spontaneous primary pneumothorax
- lung parenchymal biopsy
- Wedge resection
Old TB
Thoracoplasty (procedure to collapse a tuberculous vanity)
- deviation of the trachea towards the affected side
- flattening of the chest wall on the affected side
- posterior thoracotomy scar
- absent ribs (usually 3rd and 8th)
- dull percussion note over affected area
- reduced breath sounds with reduced vocal resonance
Phrenic nerve crush (causes ipsilateral diaphragmatic paralysis and basal lobe collapse)
- trace central
- scar over ipsilateral supravlavicular region
- reduced chest expansion
- dull percussion
- reduced air entry and vocal resonance
Investigations:
Bloods- FBC, UEC, LFT, baseline ischihara (prior to starting TB treatment)
- Mantoux test
- Quantiferon TB
Sputum AFB smear and culture
Imaging
CXR
Bronchoscopy + BAL
Management:
Acute
- oxygen, intubation or NIV
- Bronchial artery embolisation/ bronchoscopy/ surgical resection for hemoptysis
- Antibiotic (6 month) 2 months of RIPE and 2 months of PE
Lung consolidation
May be unwell, signs of respiratory distress
Decreased chest expansion on the affected side
Dull on percussion
Bronchial breathing and coarse crepitation
Increased vocal resonance
Differentials
- Consolidation
- Malignancy
- Bronchiectasis
- Pulmonary oedema
Investigations:
Bloods
ABG, FBC, renal function
Sputum CS
Imaging
CXR
Management:
Supportive and antibiotics
Lung collapse
Tracheal deviation towards affected side
Reduced chest expansion
Dull on percussion
Reduced AE on the affected side with reduced vocal resonance
Causes:
1. Intra luminal
- mucous plugging, foreign body
2. Luminal
- COPD or asthma, bronchial wall carcinoma
3. Extra luminal
- compression from surrounding lymphadenopathy, mediastinal masses, tumour
4. Non obstructive atelectasis
- compression from peleural effusion, passive
Investigations:
CXR
CT scan
Spirometry- fitness for surgery
Bronchoscopy with biopsy
Management:
MDT approach
Oxygen supplementation
Pre-bronchoscopy labs coagulopathy
Endobronchial stentint
Bronchodilators
COPD
General: SOB, coughing, pursing of the lip, active accessory muscles of respiration
Hand:
- tar staining, cyanosis, palmar erythema, steroid purpura
Trachea with be central
Chest
- barrel shaped chest, hyper inflated chest
- reduced chest expansion bilaterally
- reduced vocal remits
- hyper resonant
- reduced breath sounds with some wheeze and possible crackles
Complete investigations:
Bloods
CXR
Spirometry
- assess severity which is reflected by FEV1 <30% very severe
Sputum CS if exacerbation
Causes:
Pollution
Smoking
Alpha 1 anti trypsin
Management of COPD
Lifestyle
- Smoking cessation
- Pulmonary rehabilitation
- Influenza, pneumococcal vaccination
Medical
- Acute: Oxygen therapy, NIV
- Inhalers ICS + bronchodilators
- Orals: steroids, theophylline
- Mucolytic therapy
Roflumilast- oral phosphodiesterase 4 inhibitor
Prognosis
- BODE index (BMI, airflow obstruction, Dyspnoea and Exercise capacity)
What is SVCO?
Compression of the SVC
Dilated veins, facial oedema, severe respiratory distress, cyanosis, convulsions
Management:
Corticosteroids
Diuretics
Radiotherapy
Chemotherapy
Surgical- stenting
What is Kartnager syndrome?
Autosomal recessive
Primary genetic defect of the structure and function of sensory and motile cilia
Triad of features:
1. Situs inversus
2. Abnormal frontal sinuses causing sinusitis and bronchiectasis
3. Primary ciliary dyskinesia
Investigations:
CXR: dextrocardia, features of bronchiectasis
CT scan of lung: bronchiectasis
Transmission electron microscopy of cilia from airway biopsy
Semen analysis in post pubertal males
Measurement of nasal nitric oxide
Cystic fibrosis
Autosomal recessive disease
Mutation of the CF transmembrane CFTR gene on chromosome 7
Features:
Biliary obstruction
GI issues- pancreatic insufficiency
Bronchictasis
Investigations:
Sweat testing
Molecular genetic testing
Lung function testing
