Respiratory Flashcards
What do thoracotomy scars indicate
Pneumectomy for lobectomy for lung cancer or in older patients TB
Small right sided thoracotomy scars- minimally invasive mitral valve surgery
What are 3 thoracotomy scars
Posterolateral- most common
Anterolateral
Axillary
What looking for in hands resp exam
Clubbing- fibrosis, TB, bronchiectasis, cancer, mesothelioma, asbestos
Thenar wasting
Yellow nails
Sclerodactyly
Calcinosis
RA hand signs
Tar staining
Cyanosis
Tremor
Pulses to feel for in resp exam
Bounding- CO2 retention
Pulsus paradoxus- COPD and asthma exacerbation
Causes of bradypnoea
OSA
CO poisoning
Opioids
What looking for in face resp exam
Ptosis- horners syndrome
Conjunctival pallor
Candida from steroid inhalers
Central cyanosis
Normal cricothyroid distance and what causes
Under 5cm
Reduced if hyperexapanded lung
What looking for in inspection of chest
Scars
Chest deformities
- kyphoscoliosis can cause restrictive lung pattern
- pectus excavatum (scoliosis and marfans)
- pectus carinatum (bulging sternum from childhood resp disease)
- barrel chest from increase in anterior-posterior diameter ( COPD, CF)
What scars looking for in resp exam
Chest drain- 1 scar in axilla
Midline sternotomy- CABG, lung transplant
Posterolateral scar- transplant, pneumectomy, lobectomy
2 small scars, 1 in axilla and 1 posterolaterally indicates video assisted thoracoscopy
Indications for VATS scars
Effusion
Pneumothorax
Biopsy for cancer or mesothelioma
Pleuroidesis
Bronchial breath sounds cause
Pneumonia
Reduced breath sounds causes
Pleural effusion
Pneumothorax
Coarse crackles causes
Oedema
Pneumonia
Bronchiectasis
Increased vocal fremitus causes
Pneumonia
Lobar collapse
CREST management
Mainly focussing on symptom control
Raynauds- CCB, conservative, prostacyclin
Oesophageal dysmobility- metoclopramide, PPI if associated GORD
Renal disease- ACEi
Immunosuppressive therapy with steroids, methotrexate, cyclophosphamide or mycophenolate particularly helpful for interstitial lung diseases
Investigating CREST
Bloods- auto-antibodies anti-centromere for limited, anti-topoisomerase for diffuse
HRCT
Skin biopsy may show collagen deposition and fibrosis
COPD management
Conservative- stop smoking, pulmonary rehab, vaccinations- influenza and pneumococcal
Medical- 1st SABA or SAMA then depends on steroid responsive, if so ICS and LABA, if not LABA and LAMA. 3rd line is all options. If inhalers not tolerated or working then oral theophylline. If frequent exacerbations- prophylactic azithromycin. If meet certain criteria based off ABGs then LTOT
Surgical- lung reduction
Steroid responsive features
Atopy/asthma
Eosinophilia
Diurnal variation of over 20%
FEV1 variation of over 400ml over time
How can RA cause fibrosis
Interstitial lung
Methotrexate
Causes of lung fibrosis
Upper zones
- berryliosis
- radiation
- EAA
- ank spond
- sarcoidosis
- TB
Lower zone
- ank spond
- RA, SLE
- idiopathic
- drugs- cyclophosphamide, bleomycin, nitrofurantoin, amiodarone
How investigate pulmonary fibrosis
Simple imaging- CXR
HRCT diagnostic
BAL- help identify if inflammatory component and steroid responsive
Management of pulmonary fibrosis
Conservative- stop smoking, if drug cause, occupational or organic precipitant then avoid exposure
Manage cause- immunosuppressant for sarcoid, connective tissue diseases, if BAL reveals lymphocytosis then steroids
Anti-fibrotic agents- pirfenidone, nintenanib
LTOT
Lung transplant may be required
Indications for thoracotomy
Pneumectomy
Lobectomy- cancer, TB
Oesophageal surgery
Advantage of axillary thoracotomy
Muscle sparing
Clamshell scar
Double lung transplant
