Respiratory Flashcards
Indications for VATS
Wedge resection / segmentectomy
Lobectomy
Decortication (removal of abnormal fibrous tissue)
Bullectomy
Tx recurrent pneumothoraces
Benefits of VATS over open thoractomy
Small incision, therefore:
1) Reduced pain
2) Reduced wound complications
3) Reduced healing time
4) Reduced length of stay
Indications for lobectomy
1) Lung Ca
2) Aspergilloma
3) TB
4) Lung abscess
Investigation for Lung Ca
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
Assessing fitness for surgery
1) Full Hx & Examinations
2) LFTs, inc. transfer factor
3) Cardiopulmonary exercise testing
FEV1 for lobectomy
> 1.5L
FEV1 for pneumonectomy
> 2L
VO2max for good prognosis following pneumonectomy
> 15ml/kg/min
Histological subtypes of Lung Ca
Small Cell (20%)
Non-small Cell
- Adenocarcinoma
- Squamous cell
- Large cell carcinoma
- Neuroendocrine
Worst prognosis Lung Ca
Small cell
Rapid progressive & presents late
Rarely ammenable to surgery
Early disease - chemoradiotherapy
Late disease - palliative radiotherapy
Chest signs following lobectomy
Recent - tracheal deviation with reduced air entry in affected area
Old - expansion of other lobes, resulting in normal examination findings
Scars following VATS
3 scar (triangular)
Largest lateral chest wall - 3-6cm
Clinical signs lobectomy vs. pneumonectomy
Tracheal deviation towards penumonectomy (only deviated if recent lobectomy as lung will hyperexpand with time)
Absent breath sounds with pneumonectomy
Dull percussion with pneumonectomy
Respiratory causes of clubbing
1) Interstitial lung disease
2) Chronic suppurative disease
- CF
- Bronchiectasis
- Lung absecess
3) Lung Ca
Lung Ca associated with smoking
Squamous cell carcinoma
Inhaled therapy in COPD
Short acting drugs
- B2 agonist - salbutamol
- Muscarinic antagonists - ipratropium
Long acting agents
- B2 agonist - salmeterol
- Muscarinic - Tiotropium
- Inhaled corticosteroids
Primary vs. Secondary pneumothorax
Primary - spontaneous in otherwise healthy
Secondary - associated to underlying lung disease
Initial Mx Primary pneumothorax - breahtless patient
A->E
Escalte early
As per British Thoracic Society guidelines
Aspirate if <2cm - if symptoms resolve can discharge
If no resolution, consider chest drain
Chest drain suction in pneumothorax?
Rarely used, due to risk of re-expansion pulmonary oedema
Surgical indications in pneumothorax
Persistent air leak
Recurrent pneumothorax
Surgery for pneumothorax
Talc pleuodesis
Pleurectomy
Bullectomy, if bullae are present
Risk of recurrent pneumothorax after VATS vs. open thoractomy
VATS = 5%
Open = 1%
Ix Asthma
Baseline Obs - RR / Sats
Bloods - FBC, CRP, Renal, U&Es, RAST
ABG (in acute setting)
CXR
Peak flow
Spirometry
Bedside Fractional exhaled Nitric Oxide
Asthma - FBC findings
Check WBC - infection / recent course of steroids
Check eosinophils
What is peak flow diurnal variation
Reduction early in morning - represents poor control
Spirometry in Asthma
Obstructive picture - Reduce FEV1, preserved FVC - some reversibility following bronchodilation (>15% / 200mls FEV1)
Treatment of asthma
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)
Causes of airflow obstruction
Asthma
COPD
Bronchiectasis
Obliterative bronchiolitis (rarer)
Causes of obliterative bronchiolitis
1) Viral infection
2) Pollutants
3) GvH disease - stem cell transplant / lung transplant
Causes of bibasal inspiratory crepitations
Interstitial lung disease (IPF most common)
Bronchiectasis (creps clear with cough, coarse)
Bilateral pneumonia
Pulmonary oedema
How would you Ix patient with bibasal creps
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
Ct changes idiopathic pulmonary fibrosis
Honeycombing
Ct changes alveolitis
Ground glass shadowing
Spirometry findings - Pulmonary fibrosis
Restrictive pattern
Reduced FEV1 & FVC (preserved ratio)
Reduced total lung capacity
Reduced transfer factor
If FEV1 <80% referral to tertiary centre for specialist input
Tx interstitial lung disease
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
Anti-fibrotics agents in pulmonary fibrosis
Pirfenidone
Nintenanib
Causes of upper zone bilateral pulmonary fibrosis
CHARTS
Coal workers pneumoconioses
Hypersensitivity pneumonitis
Ankylosying spondylitis / ABPA
Radiations
TB
Sarcoidosis / Silicosis
Causes of lower zone bilateral pulmonary fibrosis
RATIO
Rheumatoid arthritis
Asbestosis
T - connective Tissue diseases (SLE, scelroderma, sjorgrens_
Idiopathic pulmonary fibrosis
Other - bronchiectasis, chemoTx, drugs (amiodarone/methotrexate)
Tertiary care review of interstitial lung disease
MDM - reviw HRCT - confirm aetiology
?needs lung biopsy
MDT
Resp ?anti-fibrotic treatment
Thoracic surgery ?lung transplant
Physio - Pulmonary rehab
OT
Resp CNS
Do you need repeat spirometry in ILD?
Yes, typically after 6 months, to determine rate of progression
Poor prognostic factors in idiopathic pulmonary fibrosis
Age
Dyspnoea
Declining pulmonary function
Pulmonary HTN
Co-existent emphysema
Extensive radiographic involvement
Treatment of non-specific interstitial pneumonia
Treat moderate to severe disease
Corticosteroids - PO or IV
+ steroid sparing agents (azathiprine / mycophenolate mofetil)
Better prognosis - NSIP vs. IPF
NSIP, although prognosis is still generally poor - 5 year mortality 15-20%
Cause of CF
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
Explains the effects of CF
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
Management of CF
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
Microbiology of CF
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
Potential non-organic findings in cystic fibrosis
Portacath - repeated courses of IV abx
Feeding tube - PEG / gastrostomy button
When is CF typically diagnosed?
At birth as part of Guthrie (heel prick) test
Diagnosis confirmed with sweat test
Chloride >30mmol/L = likely
>60mmol/L = confirmed
Life-expectancy in CF
Median in UK is 47 years
Children born today can expect to live into their 50s
Newer treatment of CF
CTFR modulating therapies, in those with certain mutations
Includes Trikafta & Symdeko
(Ivacaftor)
Shown to reduce infections and exacerbations
Incision for double lung transplant
Clamshell
Conditions where lung transplantation is considered
1) Cystic fibrosis / bronchiectasis
2) Pulmonary vascular disease
3) Pulmonary fibrosis
4) COPD - typically single lung
Double vs. single lung transplant
Better prognosis with double
Medications used following lung transplantation
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
Complications of lung transplantation
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
Contraindications to lung transplantation
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
Indications for lung transplantation
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
Median survival following lung transplants
Single 4.5 years
Double 7.5 years
Leading cause of lung transplant related death
Alveolitis obliterans
Side effects of tacrolimus therapy
Tremor
Diabetes Mellitus
Commonest indication for lung transplant
COPD - improves QoL > life expectancy
Best prognosis when BODE index >7
Ix for bronchiectasis
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
Patient with cough, discoloured & dystrophic nails
Bronchiectasis secondary to yellow nail syndrome
Management of bronchiectasis
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
Causes of bronchiectasis
Idiopathic
Immune deficiency
Autoimmune conditions - RA
Inflammatory conditions - IBD
Lobar pneumonias / pulmonary TB
Exposure to fungal mould - ABPA
History questions in suspected bronchiectasis
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
Yellow nail syndrome - triad
1) Slow growing, dystrophic nails
2) Lymphoedema
3) Resp disease, typically bronchiectasis
Bronchiectasis and infertility
CF
Primary ciliary dyskinesia
Routine investigations for suspected lung cancer
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
Subtypes of lung cancers
Small cell and non-small cell lung cancer
Non-small cell lung cancer is a typically adenocarcinomas or squamous cell carcinomas
Describe a presentation of lung cancer
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
Findings in Horner syndrome
Ptosis, miosis and anhidrosis
Due to a Pancoast tumour
Why do you get hypercalcaemia with lung cancer?
Can be secondary to bony metastasis or due to ectopic PTH secretion
Cause of unilateral pleural effusion
Think exudatice cause
- Parapneumonic effusion
2 Cinnective tissue diseases - Malignancy
Causes of a transudate
Heart / liver / kidney failure
Hypoalbuminaemia
Differentiating between trans and exudates
Lights criteria
Is exudate if
Pleural/serum protein >0.5
Lactate > 0.6
LDN> 2/3
Signs pleural fluid is empyema
Frank pus
PH<7.2
Management of malignancy associated pleural effusion
If already have diagnosis, effusion can be drained and long term catheter could be inserted. Can consider pleurodesis
What should you send pleural fluid for?
Protein
LDN
Lactate
MC&S
Acid fast bacilli
Pleural fluid with protein <25 and >35
<25 transudate
>35 exudate
Use lights criteria between these values
Commonest lung cancer in smoker and non-smoker
Smoker - squamous
Non-smoker - adenocarcinoma
Both non small cell
Early and late signs of lobectomy
Early - tracheal deviation towards due to volume loss and reduced breath sounds.
Later - due to lobe expansion normalisation of trachea and breath sounds
Most common indication for lobectomy or pneumonectomy
Non-small cell lung cancer
Central tumour - pneumonectomy
Peripheral tumour - lobectomy
Assessment prior to pneumonectomy
Performance status
Lung function tests - need FEV1>2L
Cardiopulomary exercise testing
Echocardiogram
To complete exam
Bedside investigations & spirometry
Suspected lung cancer Ix
CXR
Bloods
CT CAP
Tissue biopsy - broncho / EBUS / IR
?PET
Refer to lung Ca MDT
Ix for ILD
Bloods inc, AI and vasculitis screen
CXR
HRCT
Spirometry - expect restrictive defecit
Refer on ILD MDT
ILD - Important Hx Qs
Occupation ?asbestos
Medications ?Amio ?MTX ?Nitrofurantoin
CTD Hx
Drug Tx idiopathic pulmonary fibrosis
Perfenidone
Nintenadib
Tx non-specific interstitial pneumonia
Steroids + immunosuppression
DDx bibasal creps
ILD
Pulmonary oedema
Bronchiectasis
Bilateral pneumonia
Creps in ILD
Fine end inspiratory
Ix for suspected sarcoidosis
Serum ACE
If worried about bird related lung disease, what do you send?
Avian Precipitins
To complete resp exam
Full Hx
Obs - inc. O2 Sats
Perfrom peak flow and bedside spirometry
DDx breathless patient with normal resp exam
Anaemia
Thromboembolic disease
Pulmonary hypertension
If obese, obesity hypoventilation syndrome
Blood gas in obesity hypoventilation syndrome
T2RF
Elevated pCO2, low pO2
How is COPD severity classified?
Using GOLD criteria - using FEV1
- 1 - >80% Mild
- 2 - 50-80% Mod
- 3 - 30-50% Severe
- 4 - <30% v. severe
Drug treatment for COPD
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
Treatment of cor pulmonale
Long-term oxygen therapy to reduce pulmonary vasoconstriction
Diuretics for symptoms
Why do patients with COPD get cor pulmonale?
Chronic hypoxia leads to pulmonary vasoconstriction, resulting in pulmonary hypertension and subsequent right sided heart failure
What is LTOT?
O2 that is given for >15 hours per day
Indicated in patients with a PaO2 <7.3 or <8 with secondary polycythaemia
Role of Surgery in COPD
Lung volume reduction surgery
Bullectomy
Lung transplant
Causes of acute exacerbation of COPD
Infection, 60% either viral or bacterial
Unknown aetiology, 30%
Environmental pollution, 10%
Treatment of acute exacerbation of COPD
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
Treatments to stop smoking
Behavioural and psychological support
Nicotine replacement therapy
Bupoprion / Varenicline
COPD FEV/FVC ratio
<0.7
Transfer factor in restrictive lung disease
Reduced
Treatment of interstitial, lung disease
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
Causes of bronchiectasis
Congenital-cystic fibrosis/kartageners
Mechanical-carcinoma/granuloma
Childhood infection-whooping cough/measles/ TB
Overactive immune response-allergic bronchopulmonary especially Aspergillosis 
Gastrointestinal complication associated with cystic fibrosis in newborns
Meconium ileus
