Respiratory Flashcards
What procedures can be performed in a VATS
- Lobectomy
- Bullectomy
- Lung volume reduction surgery
- Wedge resection
- Decortication e.g. mesothelioma
- Pleurectomy (treatment of recurrent pneumothoraces)
Types of lung Ca
- Small cell lung cancer (usually presents late)
- Non-small cell lung cancer
- Squamous cell Ca
- Adenocarcinoma
- Bronchial Ca
- Large cell
- Neuroendocrine
Most common types of lung cancer
- Squamous cell cancer
- Adenocarcinoma
Indications for lobectomy/pneumonetomy
- Lung cancer (almost always non-small cell lung Ca)
- Infection e.g. TB, aspergilloma, ung abscesses
- Pulmonary nodules
Indications for lung transplant
Bronchiectasis
Cystic fibrosis
COPD
Pulmonary fibrosis
Contraindications to lung resection in lung Ca
- Reduced FEV1 (<1.5L)
- Obstructed SVC
- Paralysis of vocal cords
- Effusion (malignant)
- Distal mets
Asthma investigations
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
Investigations in asthma
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)
Spirometry in COPD
Obstructive picture:
Reduced FEV1 with preserved FVC
Reduced FEV1:FVC ratio (<0.7)
No reversibility with bronchodilator
Causes of obstructive lung disease
- Asthma
- COPD
- Bronchiectasis
Asthma management
1) SABA PRN
2) SABA + ICS
3) SABA + ICS + [LTRA or LABA]
4) Specialist drugs e.g. theophylline
Causes of wheeze
Polyphonic:
- COPD
- Asthma
- Bronchiectasis
Monophonic:
- Cardiac wheeze secondary to pulmonary oedema
Causes of bibasal creps
Coarse:
- Bronchiectasis
- Bilateral pneumonia
Fine:
- Interstitial lung disease
- Pulmonary oedema
Investigations for Interstitial lung disease
- 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
Features of ILD on CT
Honeycombing
Ground glass shadowing
Management of ILD
- 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
Anti-fibrotic agents in idiopathic pulmonary fibrosis
Pirfenidone
Nintedanib
Causes of interstitial lung disease
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
When would you consider an anti fibrotic agent in IPF?
FVC <80% predicted
- refer to teritary centre for consideration of pirfenidone or nintenadib.
Cystic fibrosis - possible extrapulmonary features on examination
- CBG monitor
- Gastrostomy tube for feeding
- Liver transplant
What does sweat test show in cystic fibrosis?
Excess chloride in sweat
Cystic fibrosis pathophysiology
- Autosomal recessive
- Mutation in CFTR gene
- Increased salt excretion results in sticky, viscous secretions which are difficult to clear
- Multisystem disease
Microbiology in cystic fibrosis
Most common: pseudomonas aeruginosa
Poor prognosis: Burkholderia
- this is an absolute contraindication to lung transplantation
Complications of cystic fibrosis
Lungs:
- Bronchiectasis
- Recurrent infections
- Increased risk pneumothorax
- Respiratory failure
Gastrointestinal:
- Pancreatic insufficiency -> malnutrition, diabetes
- Gallstones
- Liver dysfunction
Metabolic:
- Osteoporosis
Reproductive:
- Reduced fertility
Psychological effects
Management of cystic fibrosis
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
Features of cystic fibrosis examination
- Clubbing
- Coarse inspiratory crackles
- May be malnourished (pancreatic insufficiency + catabolic state)
Check for:
- Portacath or hickman line
- Gastrostomy tube
- Liver transplant scar
Causes of upper zone lung fibrosis
PHARTS
Pneumoconiosis
Histiocytosis
Ank. spondylitis
Radiation
TB
Silicosis
Causes of lower zone fibrosis
RAID
Rheumatoid arthritis
Asbestosis
Idiopathic pulmonary fibrosis
Drugs e.g. methotrexate, amiodarone
Examination findings in pneumonectomy versus lobectomy
Pneumonectomy:
- Tracheal deviation
- Absent or bronchial breath sounds
- Dull percussion
Lobectomy:
- Trachea central or mildly deviated
- Normal or reduced breath sounds
- Normal percussion
Respiratory causes of clubbing
- Interstitial lung disease (IPF)
- Chronic suppurative lung disease
- bronchiectasis, cystic fibrosis
- Lung cancer
Which lung cancer is most strongly associated with smoking?
Squamous cell carcinoma in Smokers
COPD management
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
Investigations in suspected lung Ca
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)
Lung function tests pre-operatively
Lobectomy: FEV1 > 1.5L
Pneumonectomy: FEV1 >2L
Indications for lung transplant
- COPD is the most common (usually single)
- Cystic fibrosis
- Bronchiectasis
- Pulmonary fibrosis
- Pulmonary vascular disease
Immunosuppression after lung transplant
Typically calcineurin inhibitor (tacrolimus or ciclosporin), mycophenalate and prednisolone
Complications after lung transplant
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
Contraindications to lung transplant
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
Criteria for lung transplant
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
When do you do double versus single lung transplant
Double = suppurative lung disease
- Cystic fibrosis
- Bronchiectasis
Single lung transplant
- COPD
- Interstitial lung disease
Best and worst lung transplant prognosis
Cystic fibrosis = best
Pulmonary fibrosis = worst
Causes of bronchiectasis
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)
Restrictive lung function tests - how to differentiation fibrosis versus mechanical restriction
Mechanical: normal transfer factor
Fibrosis: reduced transfer factor
Causes of unilateral/localised bronchiectasis
- Localised infection e.g. TB
- Granuloma e.g. sarcoidosis
- Foreign body
- Bronchial carcinoma
Respiratory causes of clubbing
ABC-EF
Abscess/Asbestosis
Bronchiectasis/Bronchial Ca
Cystic fibrosis
Extrinsic allergic alveolitis
Fibrosis idiopathic
Respiratory causes of clubbing and crackles
FABB
Fibrosis idiopathic
Asbestosis
Bronchiectasis
Bronchial ca
Management of bronchiectasis
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
Complications of bronchiectasis
- Lungs: abscesses, pneumothorax
- Malnutrition
- Respiratory failure
Pleural effusion mimics/DDx
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
Light’s criteria for pleural effusion
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
Features of life-threatening asthma
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%
Acute asthma exacerbation management
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
Most common lung Ca in non-smokers
adeNOcarcinoma in NON smokers
When would a pneumonectomy be performed rather than a lobectomy
Lung Ca - involving multiple lobes OR a central Ca not amenable to lobectomy
Extensive unilateral bronchiectasis
Extensive unilateral infection e.g. multiple lung abscess
Pneumothorax management
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
