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PACES > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What procedures can be performed in a VATS

A
  • Lobectomy
  • Bullectomy
  • Lung volume reduction surgery
  • Wedge resection
  • Decortication e.g. mesothelioma
  • Pleurectomy (treatment of recurrent pneumothoraces)
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2
Q

Types of lung Ca

A
  • Small cell lung cancer (usually presents late)
  • Non-small cell lung cancer
    • Squamous cell Ca
    • Adenocarcinoma
    • Bronchial Ca
    • Large cell
    • Neuroendocrine
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3
Q

Most common types of lung cancer

A
  1. Squamous cell cancer
  2. Adenocarcinoma
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4
Q

Indications for lobectomy/pneumonetomy

A
  • Lung cancer (almost always non-small cell lung Ca)
  • Infection e.g. TB, aspergilloma, ung abscesses
  • Pulmonary nodules
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5
Q

Indications for lung transplant

A

Bronchiectasis
Cystic fibrosis
COPD
Pulmonary fibrosis

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6
Q

Contraindications to lung resection in lung Ca

A
  • Reduced FEV1 (<1.5L)
  • Obstructed SVC
  • Paralysis of vocal cords
  • Effusion (malignant)
  • Distal mets
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7
Q

Asthma investigations

A

Bedside:
- SaO2
- PEFR
- ABG if acutely hypoxic

Bloods:
- FBC - eosinophilia, raised IgE
- Inflammatory markers

Imaging:
- CXR

Other tests:
- Peak flow diary
- Spirometry (obstructive)
- FEV1:FVC > 0.7 with bronchodilator reversibility in FEV1 of 12% or 200ml
- FeNO > 40 parts per billion
- Allergen testing

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8
Q

Investigations in asthma

A

Obstructive picture:
Reduced FEV1 with preserved FVC
Reduced FEV1:FVC ratio (<0.7)

FeNO (fractional exhaled nitric oxide) of >40 parts per billion

Reversibility with bronchodilators (FEV1 >12% and >200ml)

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9
Q

Spirometry in COPD

A

Obstructive picture:
Reduced FEV1 with preserved FVC
Reduced FEV1:FVC ratio (<0.7)

No reversibility with bronchodilator

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10
Q

Causes of obstructive lung disease

A
  • Asthma
  • COPD
  • Bronchiectasis
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11
Q

Asthma management

A

1) SABA PRN

2) SABA + ICS

3) SABA + ICS + [LTRA or LABA]

4) Specialist drugs e.g. theophylline

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12
Q

Causes of wheeze

A

Polyphonic:
- COPD
- Asthma
- Bronchiectasis

Monophonic:
- Cardiac wheeze secondary to pulmonary oedema

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13
Q

Causes of bibasal creps

A

Coarse:
- Bronchiectasis
- Bilateral pneumonia

Fine:
- Interstitial lung disease
- Pulmonary oedema

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14
Q

Investigations for Interstitial lung disease

A
  • Full history incl. drug history
  • Obs, especially SaO2 at rest and on exertion
  • ABG if newly hypoxic

Bloods:
- FBC, infection markers
- Autoimmune screen

Imaging:
- CXR
- HRCT

Special tests:
- Spirometry: reduced FEV1 and FVC with normal ratio, reduced transfer factor and reduced TLC
- Echocardiogram for pulm. HTN

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15
Q

Features of ILD on CT

A

Honeycombing
Ground glass shadowing

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16
Q

Management of ILD

A
  • MDT approach
  • Remove causative agent e.g. drug where possible
  • Pulmonary rehab
  • Home oxygen if needed
  • Idiopathic fibrosis: consider anti-fibrotic agent if FVC <80% predicted
  • Consider lung transplant
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17
Q

Anti-fibrotic agents in idiopathic pulmonary fibrosis

A

Pirfenidone
Nintedanib

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18
Q

Causes of interstitial lung disease

A

Idiopathic pulmonary fibrosis

Connective tissue disease:
- SLE
- Systemic sclerosis
- Rheumatoid arthritis

Drugs: amiodarone, methotrexate

Exposure to fibrotic agents:
- Asbestosis
- Silicon

Extrinisic allergic alveolitis (asthma + ILD)
- Bird fanciers lung
- Farmer’s lung

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19
Q

When would you consider an anti fibrotic agent in IPF?

A

FVC <80% predicted
- refer to teritary centre for consideration of pirfenidone or nintenadib.

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19
Q

Cystic fibrosis - possible extrapulmonary features on examination

A
  • CBG monitor
  • Gastrostomy tube for feeding
  • Liver transplant
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19
Q

What does sweat test show in cystic fibrosis?

A

Excess chloride in sweat

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19
Q

Cystic fibrosis pathophysiology

A
  • Autosomal recessive
  • Mutation in CFTR gene
  • Increased salt excretion results in sticky, viscous secretions which are difficult to clear
  • Multisystem disease
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19
Q

Microbiology in cystic fibrosis

A

Most common: pseudomonas aeruginosa

Poor prognosis: Burkholderia
- this is an absolute contraindication to lung transplantation

19
Q

Complications of cystic fibrosis

A

Lungs:
- Bronchiectasis
- Recurrent infections
- Increased risk pneumothorax
- Respiratory failure

Gastrointestinal:
- Pancreatic insufficiency -> malnutrition, diabetes
- Gallstones
- Liver dysfunction

Metabolic:
- Osteoporosis

Reproductive:
- Reduced fertility

Psychological effects

19
Q

Management of cystic fibrosis

A

MDT approach in specialist centre

Chest:
- Regular physiotherapy
- Cough assist devices
- Mucolytics
- Antibiotic prophylaxis (nebulised Abx + oral azithromycin)

GI:
- Pancreatic insufficiency: Creon, fat-soluble vitamins
- Nutritional support

Psychological support

Some go on to lung transplant

19
Q

Features of cystic fibrosis examination

A
  • Clubbing
  • Coarse inspiratory crackles
  • May be malnourished (pancreatic insufficiency + catabolic state)

Check for:
- Portacath or hickman line
- Gastrostomy tube
- Liver transplant scar

20
Q

Causes of upper zone lung fibrosis

A

PHARTS

Pneumoconiosis
Histiocytosis
Ank. spondylitis
Radiation
TB
Silicosis

21
Q

Causes of lower zone fibrosis

A

RAID

Rheumatoid arthritis
Asbestosis
Idiopathic pulmonary fibrosis
Drugs e.g. methotrexate, amiodarone

22
Q

Examination findings in pneumonectomy versus lobectomy

A

Pneumonectomy:
- Tracheal deviation
- Absent or bronchial breath sounds
- Dull percussion

Lobectomy:
- Trachea central or mildly deviated
- Normal or reduced breath sounds
- Normal percussion

23
Q

Respiratory causes of clubbing

A
  • Interstitial lung disease (IPF)
  • Chronic suppurative lung disease
    • bronchiectasis, cystic fibrosis
  • Lung cancer
24
Q

Which lung cancer is most strongly associated with smoking?

A

Squamous cell carcinoma in Smokers

25
Q

COPD management

A

1) SABA (salbumtaol) or SAMA (iptratropium)

2) Add a LABA (salmeterol) and either:
- ICS (if steroid responsive)
- LAMA e.g. tiotropium (if not steroid responsive)

3) LABA + LAMA + ICS

26
Q

Investigations in suspected lung Ca

A

Imaging:
- CXR
- CT Chest
- Staging CT CAP

Tissue diagnosis: can be done via
- Bronchoscopy
- EBUS with transbronchial needle aspiration)
- CT-guided biopsy

Spirometry - helps guide management

Bloods incl. Na (SIADH) and Ca (hyperCa of malignancy)

27
Q

Lung function tests pre-operatively

A

Lobectomy: FEV1 > 1.5L

Pneumonectomy: FEV1 >2L

28
Q

Indications for lung transplant

A
  • COPD is the most common (usually single)
  • Cystic fibrosis
  • Bronchiectasis
  • Pulmonary fibrosis
  • Pulmonary vascular disease
29
Q

Immunosuppression after lung transplant

A

Typically calcineurin inhibitor (tacrolimus or ciclosporin), mycophenalate and prednisolone

30
Q

Complications after lung transplant

A

Acutely:
- Graft rejection
- Opportunistic infections (bacterial, mycobacterial, fungal)

Longer term:
1) Bronchiolitis obliterans (usually a terminal event) - leading cause of death after 1 year

2) Malignancies
- PTLD (post transplant lymphoproliferative disease)
- Skin malignancies

3) Adverse effects from medications
- Metabolic complications e.g. diabetes
- Renal impairment

31
Q

Contraindications to lung transplant

A

Absolute contraindications:
- Malignancy in last 5 years
- Current smokers
- Recreational drug use
- Low probability of engaging with post-transplant care e.g. severe cognitive dysfunction or mental health

Relative contraindications:
- Age >65
- BMI >30 or malnutrition
- Resistant organism colonisation e.g. Burkholderia

32
Q

Criteria for lung transplant

A

1) >50% risk of death from lung disease if transplant is not performed

2) >80% likelihood of surviving 90 days post transplant

3) >80% likelihood of 5-year post-transplant survival

33
Q

When do you do double versus single lung transplant

A

Double = suppurative lung disease
- Cystic fibrosis
- Bronchiectasis

Single lung transplant
- COPD
- Interstitial lung disease

34
Q

Best and worst lung transplant prognosis

A

Cystic fibrosis = best

Pulmonary fibrosis = worst

35
Q

Causes of bronchiectasis

A

1) Recurrent infections:
- Recurrent childhood infections e.g. measles, pertussis
- Recurrent aspiration pneumonia
- Immunodeficiencies: primary (hypogammaglobulinaemia), secondary (HIV)

2) Congenital disease
- Cystic fibrosis
- Primary ciliary dyskinesia
- Kartageners (would expect situs inversus)

3) Connective tissue disorders
- Rheumatoid arthritis
- SLE

4) ABPA - Allergic BronchoPulmonary Aspergillosis
- Asthma + central bronchiectasis (triggered by aspergillus mould)

36
Q

Restrictive lung function tests - how to differentiation fibrosis versus mechanical restriction

A

Mechanical: normal transfer factor

Fibrosis: reduced transfer factor

37
Q

Causes of unilateral/localised bronchiectasis

A
  • Localised infection e.g. TB
  • Granuloma e.g. sarcoidosis
  • Foreign body
  • Bronchial carcinoma
38
Q

Respiratory causes of clubbing

A

ABC-EF

Abscess/Asbestosis
Bronchiectasis/Bronchial Ca
Cystic fibrosis
Extrinsic allergic alveolitis
Fibrosis idiopathic

39
Q

Respiratory causes of clubbing and crackles

A

FABB

Fibrosis idiopathic
Asbestosis
Bronchiectasis
Bronchial ca

40
Q

Management of bronchiectasis

A

1) EDUCATION:
- Smoking cessation
- Vaccinations

2) CAUSE: identify and treat if possible

3) MUCUS CLEARANCE:
- Chest physio
- Mucolytics eg carbocisteine
- Cough assist devices

4) ANTIBIOTICS:
- Must take sputum samples
- 2/52 targeted course Abx - usually nebulised specific to patients colonisation
- If >2 chest infections per year despite this - prophylaxis

5) NUTRITIONAL SUPPORT: dietitian review

41
Q

Complications of bronchiectasis

A
  • Lungs: abscesses, pneumothorax
  • Malnutrition
  • Respiratory failure
42
Q

Pleural effusion mimics/DDx

A

1) Raised hemidiaphragm
- Lobar collapse
- Phrenic nerve palsy

2) Pleural thickening e.g. mesothelioma

3) Consolidation e.g. pneumonia

4) Mass lesion e.g. malignnacy

43
Q

Light’s criteria for pleural effusion

A

Exudative if one of the following is met:

1) Pleural fluid protein divided by serum protein is >0.5

2) Pleural fluid LDH divided by serum LDH >0.6

3) Pleural fluid LDH is >2/3rds the upper normal limit of LDH

44
Q

Features of life-threatening asthma

A

CCHESS 33

pCO2 normal/high
- pCO2 becomes normal → acidotic; so acidosis also a life-threatening sign

Confusion

Hypotension

Exhaustion

Silent chest

Sats <94%

PEFR <33%

45
Q

Acute asthma exacerbation management

A

Sit upright

High-flow O2

B2B Salbutamol and Ipratropium nebs

Steroids

If PEFR not improving after nebs, consider salbutamol infusion + IV Mg (causes smooth muscle relaxation)

Repeat ABGs - if pCO2 not improving despite treatment, discuss with ITU

If life-threatening: intubate and ventilate

46
Q

Most common lung Ca in non-smokers

A

adeNOcarcinoma in NON smokers

47
Q

When would a pneumonectomy be performed rather than a lobectomy

A

Lung Ca - involving multiple lobes OR a central Ca not amenable to lobectomy

Extensive unilateral bronchiectasis

Extensive unilateral infection e.g. multiple lung abscess

48
Q

Pneumothorax management

A

Primary PTX
- <2cm and not short of breath: discharge
- >2cm or short of breath: needle aspiration

Secondary PTX
- 0-1cm: Admit for observation, oxygen
- 1-2cm or SOB: Needle aspiration
- >2cm: chest drain

49
Q
A

PACES (5 decks)

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