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Respiratory Flashcards

1
Q

Indications for VATS

A

Wedge resection / segmentectomy
Lobectomy
Decortication (removal of abnormal fibrous tissue)
Bullectomy
Tx recurrent pneumothoraces

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2
Q

Benefits of VATS over open thoractomy

A

Small incision, therefore:
1) Reduced pain
2) Reduced wound complications
3) Reduced healing time
4) Reduced length of stay

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3
Q

Indications for lobectomy

A

1) Lung Ca
2) Aspergilloma
3) TB
4) Lung abscess

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4
Q

Investigation for Lung Ca

A

1) Hx & Clincal examination
2) CXR
3) Staging CT CAP
4) Tissue diagnosis via bronchoscopy / EBUS / CT-guided biopsy
5) Consider CT PET if curative Tx considered
6) Surgical work up

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5
Q

Assessing fitness for surgery

A

1) Full Hx & Examinations
2) LFTs, inc. transfer factor
3) Cardiopulmonary exercise testing

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6
Q

FEV1 for lobectomy

A

> 1.5L

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7
Q

FEV1 for pneumonectomy

A

> 2L

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8
Q

VO2max for good prognosis following pneumonectomy

A

> 15ml/kg/min

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9
Q

Histological subtypes of Lung Ca

A

Small Cell (20%)

Non-small Cell
- Adenocarcinoma
- Squamous cell
- Large cell carcinoma
- Neuroendocrine

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10
Q

Worst prognosis Lung Ca

A

Small cell
Rapid progressive & presents late
Rarely ammenable to surgery

Early disease - chemoradiotherapy
Late disease - palliative radiotherapy

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11
Q

Chest signs following lobectomy

A

Recent - tracheal deviation with reduced air entry in affected area

Old - expansion of other lobes, resulting in normal examination findings

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12
Q

Scars following VATS

A

3 scar (triangular)
Largest lateral chest wall - 3-6cm

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13
Q

Clinical signs lobectomy vs. pneumonectomy

A

Tracheal deviation towards penumonectomy (only deviated if recent lobectomy as lung will hyperexpand with time)

Absent breath sounds with pneumonectomy

Dull percussion with pneumonectomy

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14
Q

Respiratory causes of clubbing

A

1) Interstitial lung disease
2) Chronic suppurative disease
- CF
- Bronchiectasis
- Lung absecess
3) Lung Ca

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15
Q

Lung Ca associated with smoking

A

Squamous cell carcinoma

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16
Q

Inhaled therapy in COPD

A

Short acting drugs
- B2 agonist - salbutamol
- Muscarinic antagonists - ipratropium

Long acting agents
- B2 agonist - salmeterol
- Muscarinic - Tiotropium
- Inhaled corticosteroids

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17
Q

Primary vs. Secondary pneumothorax

A

Primary - spontaneous in otherwise healthy

Secondary - associated to underlying lung disease

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18
Q

Initial Mx Primary pneumothorax - breahtless patient

A

A->E
Escalte early
As per British Thoracic Society guidelines

Aspirate if <2cm - if symptoms resolve can discharge
If no resolution, consider chest drain

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19
Q

Chest drain suction in pneumothorax?

A

Rarely used, due to risk of re-expansion pulmonary oedema

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20
Q

Surgical indications in pneumothorax

A

Persistent air leak
Recurrent pneumothorax

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21
Q

Surgery for pneumothorax

A

Talc pleuodesis
Pleurectomy
Bullectomy, if bullae are present

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22
Q

Risk of recurrent pneumothorax after VATS vs. open thoractomy

A

VATS = 5%
Open = 1%

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23
Q

Ix Asthma

A

Baseline Obs - RR / Sats
Bloods - FBC, CRP, Renal, U&Es, RAST
ABG (in acute setting)
CXR
Peak flow
Spirometry
Bedside Fractional exhaled Nitric Oxide

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24
Q

Asthma - FBC findings

A

Check WBC - infection / recent course of steroids
Check eosinophils

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25
Q

What is peak flow diurnal variation

A

Reduction early in morning - represents poor control

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26
Q

Spirometry in Asthma

A

Obstructive picture - Reduce FEV1, preserved FVC - some reversibility following bronchodilation (>15% / 200mls FEV1)

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27
Q

Treatment of asthma

A

Stepwise approach, outlined by BTS guidelines

1) Short acting B2 agonist
2) Add inhaled corticosteroid
3) Trial combined corticosteroid with long acting B2 agonist
4) Trial montelukast (leukotriene receptor antagonist)

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28
Q

Causes of airflow obstruction

A

Asthma
COPD
Bronchiectasis
Obliterative bronchiolitis (rarer)

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29
Q

Causes of obliterative bronchiolitis

A

1) Viral infection
2) Pollutants
3) GvH disease - stem cell transplant / lung transplant

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30
Q

Causes of bibasal inspiratory crepitations

A

Interstitial lung disease (IPF most common)
Bronchiectasis (creps clear with cough, coarse)
Bilateral pneumonia
Pulmonary oedema

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31
Q

How would you Ix patient with bibasal creps

A

Full Hx and clinical exams
Observations
Bloods - FBC, CRP, Renal, U&Es, LFTs, NT-proBNP, CTD screen (ESR, RF, dsDNA, ANCA, ANA)
ABG ?needs LTOT
CXR -> HR CT Chest
TTE ?Pulmonary HTN ?R sided function
Spirometry

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32
Q

Ct changes idiopathic pulmonary fibrosis

A

Honeycombing

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33
Q

Ct changes alveolitis

A

Ground glass shadowing

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34
Q

Spirometry findings - Pulmonary fibrosis

A

Restrictive pattern
Reduced FEV1 & FVC (preserved ratio)
Reduced total lung capacity
Reduced transfer factor

If FEV1 <80% referral to tertiary centre for specialist input

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35
Q

Tx interstitial lung disease

A

MDT approach

Physio
OT
Resp nurses
Aim to improve dyspnoea & QoL

?connective tissue disorder - treat underlying cause with disease modying agents

?alveolitis ?needs steroids

Anti-fibrotics agents in pulmonary fibrosis

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36
Q

Anti-fibrotics agents in pulmonary fibrosis

A

Pirfenidone
Nintenanib

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37
Q

Causes of upper zone bilateral pulmonary fibrosis

A

CHARTS

Coal workers pneumoconioses
Hypersensitivity pneumonitis
Ankylosying spondylitis / ABPA
Radiations
TB
Sarcoidosis / Silicosis

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38
Q

Causes of lower zone bilateral pulmonary fibrosis

A

RATIO

Rheumatoid arthritis
Asbestosis
T - connective Tissue diseases (SLE, scelroderma, sjorgrens_
Idiopathic pulmonary fibrosis
Other - bronchiectasis, chemoTx, drugs (amiodarone/methotrexate)

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39
Q

Tertiary care review of interstitial lung disease

A

MDM - reviw HRCT - confirm aetiology
?needs lung biopsy

MDT
Resp ?anti-fibrotic treatment
Thoracic surgery ?lung transplant
Physio - Pulmonary rehab
OT
Resp CNS

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40
Q

Do you need repeat spirometry in ILD?

A

Yes, typically after 6 months, to determine rate of progression

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41
Q

Poor prognostic factors in idiopathic pulmonary fibrosis

A

Age
Dyspnoea
Declining pulmonary function
Pulmonary HTN
Co-existent emphysema
Extensive radiographic involvement

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42
Q

Treatment of non-specific interstitial pneumonia

A

Treat moderate to severe disease

Corticosteroids - PO or IV
+ steroid sparing agents (azathiprine / mycophenolate mofetil)

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43
Q

Better prognosis - NSIP vs. IPF

A

NSIP, although prognosis is still generally poor - 5 year mortality 15-20%

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44
Q

Cause of CF

A

Autosomal recessive
CFTR gene (long arm Ch 7)
Commonest mutation is delta F508
Results in cellular water retention, therefore, thick mucus

Also affects digestive system -> pancreatic insufficiency, and reproductive system

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45
Q

Explains the effects of CF

A

Multisystem disease

Mainly effects Resp -> bronchiectasis, with productive cough and inspiratory creps (usually upper zones)
Clubbing
Digestive -> pancreastic insufficiency, need CREON and fat soluble vitamins
Can result in liver failiure
Gallstones, kidney stones
Respoductive issues

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46
Q

Management of CF

A

Managed in specialist centre with MDT, follow guidelines established by British Thoracic Society

Respiratory physicians - regular nebulised mucolytics and hypertonic saline, regular PO azithromycin as prophylaxis , usually regular courses of IV antibiotics

Regular chest physiotherapy, positional drainage and enhanced breathing technqiues to drain mucus

Creon and fat soluble vitamins, input from dieticians ?nutritional supplemental ?PEG

47
Q

Microbiology of CF

A

Most patients are colonised with bacteria

Most commonly pseudomonas aeruginosa

Bulkholderia cepacia carries poorer prognosis & myocbactrium abscesses - both absolute contraindication to lung transplantation

In childhood, staphylococcal infections are most common

48
Q

Potential non-organic findings in cystic fibrosis

A

Portacath - repeated courses of IV abx

Feeding tube - PEG / gastrostomy button

49
Q

When is CF typically diagnosed?

A

At birth as part of Guthrie (heel prick) test

Diagnosis confirmed with sweat test
Chloride >30mmol/L = likely
>60mmol/L = confirmed

50
Q

Life-expectancy in CF

A

Median in UK is 47 years
Children born today can expect to live into their 50s

51
Q

Newer treatment of CF

A

CTFR modulating therapies, in those with certain mutations

Includes Trikafta & Symdeko
(Ivacaftor)

Shown to reduce infections and exacerbations

52
Q

Incision for double lung transplant

A

Clamshell

53
Q

Conditions where lung transplantation is considered

A

1) Cystic fibrosis / bronchiectasis
2) Pulmonary vascular disease
3) Pulmonary fibrosis
4) COPD - typically single lung

54
Q

Double vs. single lung transplant

A

Better prognosis with double

55
Q

Medications used following lung transplantation

A

Immunosuppressive medications to prevent organ rejection - typically tacrolimus, mycophenolate mofetil, steroids

Ciclosporin previously, but risk of renal failure

Also regular prophylactic medications to prevent opportunistic infections

56
Q

Complications of lung transplantation

A

Acute
- Hyperacute / acute rejection - common within 6 months
- Opportunisitic infections

Chronic
- Alveolitis obliterans (chronic rejection)
- Malignancy (lymphoproliferative most common)
- Infections - bacterial / mycobacterial / fungal / viral
- Steroid side effects - Cushings / osetoporosis / DMs

57
Q

Contraindications to lung transplantation

A

Malignancy within last 5 years
Other end organ dysfunction
Acute illnesses
Infection with highly resistant organisms (E.g. mycobacerium abscessus)
High (>35)/Low BMI
Smokers or drug use
Mental health disorders which would result in poor medication / clinic compliance
Severe impaired functional status
Age>65

58
Q

Indications for lung transplantation

A

Chronic end-stage lung failure

Sick enough to need
Fit enough to tolerate

1) >50% chance of death within 2 years
2) >80% likelihood of surviving 90 days post transplant
3) >80% survival at 5 years from general medical perspective given good graft function

59
Q

Median survival following lung transplants

A

Single 4.5 years
Double 7.5 years

60
Q

Leading cause of lung transplant related death

A

Alveolitis obliterans

61
Q

Side effects of tacrolimus therapy

A

Tremor
Diabetes Mellitus

62
Q

Commonest indication for lung transplant

A

COPD - improves QoL > life expectancy

Best prognosis when BODE index >7

63
Q

Ix for bronchiectasis

A

Bloods - FBC, CRP, Renal, U&Es, Liver, HIV, IGs, Aspergillus serology

Sputum MCS inc. fungal and mycobacterium

CXR
Consider HR CT chest

Spirometry

CF testing for patients aged <40

64
Q

Patient with cough, discoloured & dystrophic nails

A

Bronchiectasis secondary to yellow nail syndrome

65
Q

Management of bronchiectasis

A

Involvement of Respiratory MDT

Management of acute infection - 2 week course of antibiotics, guided by sputum culture

Chest physiotherapy - to aid postural drainage, active breathing cycle techniques

Medical - Consider nebulised mucolytic if there is plugging, e.g. hypertonic NaCl, consider long term macrolide prophylaxis E.g. Azithromycin

Nebulised antibiotics may be required in complicated / pseudomonal infection (colistin)

Annual pneumococcal / influenza vaccines

66
Q

Causes of bronchiectasis

A

Idiopathic
Immune deficiency
Autoimmune conditions - RA
Inflammatory conditions - IBD
Lobar pneumonias / pulmonary TB
Exposure to fungal mould - ABPA

67
Q

History questions in suspected bronchiectasis

A

1) Chest symptoms - chest pain, cough, sputum colour volume, chest infections per year, antibiotic courses, breathlessness, haemoptysis and wheeze

2) Ask about associated inflammatory / automimmune / infective symptoms

3) Travel Hx - exposure to TB

4) Any exposure to mould

68
Q

Yellow nail syndrome - triad

A

1) Slow growing, dystrophic nails
2) Lymphoedema
3) Resp disease, typically bronchiectasis

69
Q

Bronchiectasis and infertility

A

CF
Primary ciliary dyskinesia

70
Q

Routine investigations for suspected lung cancer

A

Full history and general examination
Full set of observations
Routine blood tests looking for end organ dysfunction (HypoNa associated with SIADH - SCLC, Hypcalacaemia, clotting for tissue biopsy)
CXR
Sputum MCS
Spirometry

Staging CT CAP

Tissue diagnosis via bronchoscopy, EBUS, CT-guided biopsy

71
Q

Subtypes of lung cancers

A

Small cell and non-small cell lung cancer

Non-small cell lung cancer is a typically adenocarcinomas or squamous cell carcinomas

72
Q

Describe a presentation of lung cancer

A

Patients may present with lethargy loss of appetite and weight loss

Complaining of shortness of breath and haemoptysis

Change in voice

SVC obstruction - arm and face, swelling and dilated veins

Complications of hypercalcaemia secondary to cancer - bone pain and polydipsia

73
Q

Findings in Horner syndrome

A

Ptosis, miosis and anhidrosis
Due to a Pancoast tumour

73
Q

Why do you get hypercalcaemia with lung cancer?

A

Can be secondary to bony metastasis or due to ectopic PTH secretion

74
Q

Cause of unilateral pleural effusion

A

Think exudatice cause

  1. Parapneumonic effusion
    2 Cinnective tissue diseases
  2. Malignancy
75
Q

Causes of a transudate

A

Heart / liver / kidney failure
Hypoalbuminaemia

76
Q

Differentiating between trans and exudates

A

Lights criteria

Is exudate if

Pleural/serum protein >0.5
Lactate > 0.6
LDN> 2/3

77
Q

Signs pleural fluid is empyema

A

Frank pus
PH<7.2

78
Q

Management of malignancy associated pleural effusion

A

If already have diagnosis, effusion can be drained and long term catheter could be inserted. Can consider pleurodesis

79
Q

What should you send pleural fluid for?

A

Protein
LDN
Lactate
MC&S
Acid fast bacilli

80
Q

Pleural fluid with protein <25 and >35

A

<25 transudate
>35 exudate
Use lights criteria between these values

81
Q

Commonest lung cancer in smoker and non-smoker

A

Smoker - squamous
Non-smoker - adenocarcinoma
Both non small cell

82
Q

Early and late signs of lobectomy

A

Early - tracheal deviation towards due to volume loss and reduced breath sounds.
Later - due to lobe expansion normalisation of trachea and breath sounds

83
Q

Most common indication for lobectomy or pneumonectomy

A

Non-small cell lung cancer
Central tumour - pneumonectomy
Peripheral tumour - lobectomy

84
Q

Assessment prior to pneumonectomy

A

Performance status
Lung function tests - need FEV1>2L
Cardiopulomary exercise testing
Echocardiogram

85
Q

To complete exam

A

Bedside investigations & spirometry

86
Q

Suspected lung cancer Ix

A

CXR
Bloods
CT CAP
Tissue biopsy - broncho / EBUS / IR
?PET
Refer to lung Ca MDT

87
Q

Ix for ILD

A

Bloods inc, AI and vasculitis screen
CXR
HRCT
Spirometry - expect restrictive defecit

Refer on ILD MDT

88
Q

ILD - Important Hx Qs

A

Occupation ?asbestos
Medications ?Amio ?MTX ?Nitrofurantoin
CTD Hx

89
Q

Drug Tx idiopathic pulmonary fibrosis

A

Perfenidone
Nintenadib

90
Q

Tx non-specific interstitial pneumonia

A

Steroids + immunosuppression

91
Q

DDx bibasal creps

A

ILD
Pulmonary oedema
Bronchiectasis
Bilateral pneumonia

92
Q

Creps in ILD

A

Fine end inspiratory

93
Q

Ix for suspected sarcoidosis

A

Serum ACE

94
Q

If worried about bird related lung disease, what do you send?

A

Avian Precipitins

95
Q

To complete resp exam

A

Full Hx
Obs - inc. O2 Sats
Perfrom peak flow and bedside spirometry

96
Q

DDx breathless patient with normal resp exam

A

Anaemia
Thromboembolic disease
Pulmonary hypertension
If obese, obesity hypoventilation syndrome

97
Q

Blood gas in obesity hypoventilation syndrome

A

T2RF
Elevated pCO2, low pO2

98
Q

How is COPD severity classified?

A

Using GOLD criteria - using FEV1
- 1 - >80% Mild
- 2 - 50-80% Mod
- 3 - 30-50% Severe
- 4 - <30% v. severe

99
Q

Drug treatment for COPD

A

Short acting bronchodilator
- Salbutamol

Long acting, bronchodilators
- Long acting, beta-2 agonists - salmeterol
- Long acting, anticholinergics - tiotropium

Inhaled corticosteroids

Oral corticosteroids

Sometimes have combined treatments (both bronchodilator and corticosteroids)

In severe disease, theophylline + LTOT + NIV

100
Q

Treatment of cor pulmonale

A

Long-term oxygen therapy to reduce pulmonary vasoconstriction

Diuretics for symptoms

101
Q

Why do patients with COPD get cor pulmonale?

A

Chronic hypoxia leads to pulmonary vasoconstriction, resulting in pulmonary hypertension and subsequent right sided heart failure

102
Q

What is LTOT?

A

O2 that is given for >15 hours per day

Indicated in patients with a PaO2 <7.3 or <8 with secondary polycythaemia

103
Q

Role of Surgery in COPD

A

Lung volume reduction surgery
Bullectomy
Lung transplant

104
Q

Causes of acute exacerbation of COPD

A

Infection, 60% either viral or bacterial
Unknown aetiology, 30%
Environmental pollution, 10%

105
Q

Treatment of acute exacerbation of COPD

A

Managed with A -> E approach
Oxygen saturation target

Treat with nebulised, bronchodilators and anticholinergics
Oral steroids - Pred 30mg 5 days
Consider Theophylline
Consider non-invasive ventilation and escalation to intensive care

106
Q

Treatments to stop smoking

A

Behavioural and psychological support
Nicotine replacement therapy
Bupoprion / Varenicline

107
Q

COPD FEV/FVC ratio

A

<0.7

108
Q

Transfer factor in restrictive lung disease

A

Reduced

109
Q

Treatment of interstitial, lung disease

A

Diagnosis made in an ILDMDT meeting using HRCT images and possibly lung biopsy to results

Idiopathic, pulmonary fibrosis can be treated with perfenidone or nintenanib

If drug induced stop offending medication

If related to connective tissue disease, treat underlying cause

110
Q
A
111
Q

Causes of bronchiectasis

A

Congenital-cystic fibrosis/kartageners
Mechanical-carcinoma/granuloma
Childhood infection-whooping cough/measles/ TB
Overactive immune response-allergic bronchopulmonary especially Aspergillosis 

112
Q

Gastrointestinal complication associated with cystic fibrosis in newborns

A

Meconium ileus

PACES (6 decks)

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