Respiratory Flashcards
What are the indications of thoracotomy scar (anterior or posterior)
- lobectomy
- pneumonectomy
- open lung biopsy
- lung volume reduction/bullectomy
- single lung transplants
What are the indications of clamshell incision scar
- bilateral lung transplant
- widespread traumatic chest injury requiring bilateral access
What are the indications of VATS
- biopsy/removal of masses/LNs
- pleurodesis for recurrent effusion
- recurrent PTX
- lobectomy/segmentectomy
- bullectomy
- decortication
What are the benefits of VATS over open thoracotomy
- reduced pain
- reduced wound complications
- reduced healing time
- reduced length of stay
What are the main indications of a lobectomy
- lung cancer
- infection (aspergilloma/TB), lung abscess
What FEV1 is preferred for lobectomy
> 1.5
What FEV1 is required for a pneumonectomy
> 2
What VO2 max confers good prognosis after thoracotomy
VO2 max > 15ml/kg/min
Can examination of chest after lobectomy be normal?
Yes if operation was some time ago, adjacent lope can hyperinflate
Which NSCLC is most strongly associated with smoking
SCC
What is the benefit of thoracotomy over VATS for pneumothorax
Thoracotomy has reduced risk of recurrence of PTX
What are the causes of bilateral pleural effusion
CCF, hypoalbuminaemia, renal failure, liver failure, SLE/other AI causes, widespread malignancy, bilateral PE
What are the causes of obstructive airway disease
Asthma, COPD, bronchiectasis, Bronchiolitis obliterans
Which lung condition causes fixed airway obstruction after lung transplant
Bronchiolitis obliterans
What classes as reversibility on spirometry
200ml improvement in FEV1 or 15% change compared to baseline
What are the differentials for bibasal inspiratory crepitations
Pulmonary fibrosis
Bronchiectasis
Infection
Heart failure
What are the causes of a low TLCO (transfer factor)
Pulmonary fibrosis
Pneumonia
PE
Pulmonary oedema
COPD
Anaemia
Low cardiac output
Sarcoidosis
What are the causes of a raised TLCO (transfer factor)
Pulmonary haemorrhage
Asthma
Polycythaemia
Left-to-right cardiac shunt
Exercise
What causes increased KCO (transfer coefficient) with normal/low TLCO (transfer factor)
Pneumonectomy/lobectomy
Scoliosis
Which antifibrotic agents are used to treat IPF
Pirfenidone, nintedanib
What will pulmonary fibrosis show on lung function tests
- Restrictive pattern (reduced FEV1 and FVC but normal ratios)
- reduced total lung capacity
- reduced transfer factor
What finding on HRCT suggests pulmonary fibrosis that will respond well to steroids
Ground glass changes (inflammation)
What are the 2 most common morphologies of ILD
- Usual interstitial pneumonia
- Non-specific interstitial pneumonia
What are the differences between UIP and NSIP
UIP: honeycombing, less responsive to steroids
NSIP: ground glass opacification, more responsive to steroids
What is pneumoconiosis
Any lung disease causes by inhalation of dust and fibres - includes asbestosis, silicosis and coal workers pneumoconiosis
What is seen on HRCT in bronchiectasis
Signet ring sign
What is the surgical management of pulmonary fibrosis
Single lung transplant can be considered
What FEV1 is antifibrotic treatment indicated for IPF
50 - 80%
Is biopsy needed to diagnose IPF?
Not if the MDT is happy with the diagnosis from history, exam, PFTs and HRCT
When is biopsy useful in ILD
When there is diagnostic uncertainty after initial tests
How is ILD monitored after diagnosis
PFTs at 6 months to determine speed of progression and need for treatment
Which organism confers worse prognosis in cystic fibrosis
Burkholderia
Which organism is a direct contraindication for lung transplant in cystic fibrosis
Burkholderia
Where in the lungs does bronchiectasis tend to occur most in CF patients
Upper lobes
What is the non-pharmacological management of CF
- MDT (CF specialist, PT, dietician, SN)
- Daily chest physio (postural drainage)
- Vaccinations
What are the indications of single lung transplant
COPD, pulmonary fibrosis
What are the indications of double lung transplant
CF, bronchiectasis, pulmonary hypertension
What is the leading cause of death after the first year of lung transplant
Bronchiolitis obliterans
What is the most common malignancy in the first year after lung transplant
Lymphoproliferative disorder
Which patients with UIP and fibrotic NSIP should be referred for consideration of lung transplant
All patients with UIP/fibrotic NSIP that have no absolute contraindications
When should CF patients be referred for lung transplant
FEV1 <30%
Significant pulm HTN
High exacerbation frequency
Recurrent PTX
Requirement for NIV
What is the most common indication for lung transplant worldwide
COPD (40%)
Which blood tests are important in bronchiectasis along with basics
HIV
Immuloglobulins
Aspergillus serology
CF genetic testing if <40 yrs old
Which conditions might benefit from a positive expiratory pressure device
COPD, CF, bronchiectasis (helps bring up mucous)
What causes traction bronchiectasis
Bronchiectatic dilation from adjacent lung fibrosis
What are the causes of bronchiectasis
- CF, PCD
- Immunodeficiency
- Post-infectious
- Rheumatological
- ABPA
- Yellow nail syndrome
- Traction (PF)
- Idiopathic
What is the most common lung condition associated with inflammatory myositis (eg polymyositis)
ILD
What are the differential diagnoses of reduced breath sounds with tracheal deviation
- Pneumonectomy
- Collapse of a lobe
- Pleural effusion (trachea deviated away)
- Tension pneumothorax
What are the causes of lung collapse
- Intra-luminal: mucous plugging, FB
- Luminal: dynamic obstruction (COPD), bronchial wall carcinoma
- Extra-luminal: lymphadenopathy, mediastinal mass, primary/metastatic lung cancer
- Atelectasis: compressive (effusion), adhesive (ARDS)
Why is spirometry important in the work up for suspected lung cancer
Will guide on suitability for surgery
Where are lung squamous cell carcinomas usually found
More centrally (adeno = peripheral)
What may be heard on auscultation of a patient with COPD
Expiratory polyphonic wheeze (crackles if consolidation too), reduced breath sounds at apices
What signs are suggestive of cor pulmonale
Raised JVP, ankle oedema, RV heave, loud P2 with PSM of TR
What distinguishes COPD from chronic asthma on investigations
Less reversibility - <15% change in FEV1 post-bronchodilator
Why are LFTs important in COPD
Low albumin indicates severity
What is the non pharmacological management of COPD
- smoking cessation
- cessation clinics and NRT
- pulmonary rehab
- exercise
- nutrition
- vaccinations - pneumococcal and influenza
What is the surgical management of COPD
careful patient selection is important:
- bullectomy (if bullae >1L and compressing surrounding lung)
- lung reduction surgery (only suitable for a few pts with heterogenous emphysema)
- single lung transplant
What are the indications for LTOT in COPD
- non-smoker
- PaO2 <7.3 on RA
- PaO2 <8 if cor pulmonale
- PaCO2 does not rise on O2
Improves survival by 9 months
What are the differentials of a wheezy chest
Bronchiolitis obliterans
- GPA (saddle nose)
- Rheumatoid arthritis
What are the causes of a dull lung base on percussion
- pleural effusion (dull)
- consolidation (crackles)
- collapse (trachea towards)
- previous lobectomy (scar)
- pleural thickening (normal resonance)
- raised hemidiaphragm
What organism causes rusty sputum
Pneumococcus
What will auscultation of pneumonia reveal
Focal course crackles, increases vocal resonance, bronchial breathing
What is the atypical screen for pneumonia
Serology: mycoplasma, chlamydia
Urine antigen: legionella, pneumococcal
What are the most common organisms seen in pneumonia
- Streptococcus pneumoniae
- Mycoplasma pneumoniae
- Haemophilus influenzae (COPD)
- Chlamydia pneumoniae
Which organisms should be considered in pneumonia in the immunocompromised patient
- fungal
- multi-resistant mycobacteria
- PCP
- CMV
How can severity of pneumonia be established
CURB-65 score:
- Confusion
- Urea >7
- RR >30
- BP <90 or <60
- Age >65
What are the complications of pneumonia
- sepsis
- lung abscess
- para-pneumonic effusion/empyema
- haemoptysis
What were the historical surgical treatments for tuberculosis
- Plombage
- Phrenic nerve crush
- Thoracoplasty
- Apical lobectomy
- Recurrent medical pneumothoraces
What are the serious side effects of rifampicin
Hepatitis
Enzyme inducer (COCP)
What are the serious side effects of isoniazid
Hepatitis
Peripheral neuropathy
What are the serious side effects of pyramzinamide
Hepatitis
What are the serious side effects of ethambutol
Hepatitis
Retro-bulbar neuritis
What should be checked before starting TB treatment
Baseline LFTs
Visual acuity
What should you advise patients about to start TB treatment in relation to side effects
- Check eyes for jaundice
- Monitor for change of colour vision
- Secretions likely will turn orange
- May develop paraesthesia
- Use barrier contraception
What are the causes of an exudative pleural effusion
- malignancy (primary or secondary)
- infection (parapneumonic)
- infarction (PE)
- inflammation (RA, SLE)
What are the causes of a transudate pleural effusion
- heart failure
- liver failure
- renal failure
- hypoalbuminaemia
What are the two kinds of pleurodesis and what are their indications
- Chemical
- Mechanical
Used for recurrent effusions, recurrent PTXs or persistent PTX
How can a tissue diagnosis of lung cancer be obtained
- Bronchoscopy
- CT guided biopsy
- Lymph node biopsy
- Pleural effusion cytology
What should pleural fluid be sent off for
- pH
- protein (paired with serum)
- LDH (paired with serum)
- cytology
- gram stain and culture
- acid fast bacilli
What is suggestive of effusion secondary to RA on pleural aspirate
Very low glucose <1.6 mmol/L
Which way will the trachea be deviated in a pneumonectomy
Towards the side of the pneumonectomy
List the patterns of distribution of bronchiectasis according to underlying aetiology
CF -> upper lobes
Others -> lower lobes
ABPA -> proximal airways
What are the causes of normal spirometry but reduced gas transfer
- anaemia
- pulmonary vascular disease
What are the causes of restrictive spirometry but normal gas transfer
Extrapulmonary restriction e.g. neuromuscular, scoliosis
What does a raised FeNO indicate on pulmonary function tests
Amount of inflammation in the lungs (used to aid diagnosis of asthma)
Which crackles are early inspiratory vs end inspiratory
Early inspiratory = bronchiectasis (large airways)
End inspiratory = PF (small airways)
What might an inhaler at the bedside suggest
Asthma
COPD
(Bronchiectasis)
What are the main indications for pneumonectomy
- Malignancy
- Trauma
- Chronic infection eg TB
What are the complications of lung transplant
Acute: rejection, opportunistic infection
Chronic: rejection, Bronchiolitis obliterans, malignancy, side effects of immunosuppression
What are the contraindications to lung transplant
- malignancy in last 5 years
- smoking/drug abuse
- burkholderia/mycobacterium in CF
- irreversible organ failure
- acute illness
- serious psychological illnesses
You have found a lung mass on CT that is suspicious for cancer, what is the next step
Obtain a tissue sample for diagnosis
How can a tissue diagnosis be obtained for a suspected lung cancer
- bronchoscopy
- CT-guided biopsy
- endobronchial US
- lymph node biopsy
- aspiration of pleural effusions
Which NSCLC is most commonly seen in smokers
Squamous cell
(Look for thoracotomy + tar staining, evidence of COPD)
What are the differentials of a thoracotomy scar with a normal underlying lung and no tracheal deviation
- lobectomy
- bullectomy
- lung transplant
- wedge resection
- open lung biopsy
- trauma
What indicates an educative pleural effusion on pleural fluid analysis
Protein >30g/L
Using lights criteria:
- pleural protein >0.5 of serum
- pleural LDH >0.6 of serum
- pleural LDH >2/3 UL of normal
