Respiratory Flashcards
Causes lower lobe pulmonary fibrosis
asbestosis
idiopathic pulmonary fibrosis
drugs- methotrexate/ bleomycin
CTD- SLE, rheumatoid arthritis
causes of upper lobe pulmonary fibrosis
sarcoidosis
silicosis
ankylosing spondylitis
coal workers pneumoconiosis
ABPA
radiation
TB
what are the main treatments available for pulmonary fibrosis
immunosuppression- corticosteroids, cyclophosphamide
antioxidants- NAC
supplemental oxygen
lung transplantation
anti-fibrotics- perfinidone (little evidence), nintedinib
non specific intersistitial pneumonia- steroids + immunosuppressives
what factors contribute to a lack of response to steroids in lung fibrosis
male sex
severity of symptoms
neutrophilia on BAL
predominant honeycombing on CT scan
which disorders have a high lymphocyte count BAL
organising pneumonia
sarcoidosis
hypersensitivity pneumonitis
indications for a VATS procedure
lobectomy, wedge resection, bullectomy, treatment of recurrent pneumothoraces
what are the benefits of a VATs over open thoractomy
smaller incision- less pain, reduced wound complication, shorter healing time, shorter hospital admission
what are the indications for a lobectomy or pneumonectomy
lobectomy: malignancy (peripheral), malignant nodules, abscesses (or wedge resection), aspergilloma, localised bronchiectasis
pneumonectomy: malignancy (central), bronchiectasis, trauma, TB
how would you investigate a patient with suspected lung cancer
staging CT (TAP)
broncosopy/ EBUS
tissue diagnosis with biopsy
functional imaging like PETCTh
how would you assess someone’s respiratory fitness for surgery
full history and examination
lung function test
cardiopulmonary exercise testing
if you were performing a lobectomy/ pneumonectomy what FEV1 would you want
do you know of a VO2 max that offers the best post op prognosis
Lobectomy- FEV1 of 1.5L
pneumonectomy- FEV1 of 2L
VO2 max of at least 15ml/kg/min
what are the different histological cell types of lung cancer
2 types
small cell (20%) and NSCLC (80%)
NSCLC- adenocarcinoma/ squamous cell/ large cell lung cancer/ neuroendocrinea
what are the treatment options for small cell and non small cell lung cancer
NSCLC Management
Stage I/II MFFS- surgical resection:
curative obectomy (with hilar and mediastinal lymph node resection/sampling)
Radiotherapy: Is first-line for those with stage I-III disease who are not suitable for surgery. This treatment is given with curative intent.
Chemotherapy:
Is offered to those with stage III or IV disease to improve survival and quality of life.
Combination therapy:
Adjuvant chemotherapy should be offered to patients who have undergone a complete resection
Adjuvant radiotherapy is offered to patients who have had a incomplete resection of their tumour
All patients with stage I-III disease who are not suitable for surgery should be considered for chemoradiotherapy
SCLC Management
Surgery is rarely used and only considered in very early stage I disease - SCLC is disseminated at presentation in almost all patients. The majority of SCLC patients are treated with chemotherapy in combination with radiotherapy.
indication for a lobectomy/ pneumonectomy
malignancy
bronchiectasis
empyema
TB
cystic fibrosis
what is COPD
progressive and irreversible airway obstruction due to chronic bronchitis/ emphysema, most commonly associated with smoking, but also with A1AT deficiency and coal dust
what is bronchitis
bronchitis is a clinical diagnosis- patients have a cough productive of sputum on most days for 3 months for 2 consecutive years
what is emphysema
abnormal and permanent enlargement of air spaces distal to terminal bronchioles associated with wall destruction
what are the most common pathogens in acute infective exacerbations of COPD
strep pneumonia
haem influenza
moraxella cattarhalish
how would you manage an acute IECOPD
1- controlled oxygen with aim saturations based on whether or not they are a CO2 retainer which can be ascertained from an ABG
2) bronchodilators via nebuliser
3) abx- commonly doxycycline
4) steroids
5) NIV if any evidence of type 2 respiratory failure
what are the causes of a pleural effusion
transudative (protein level <30g/L)
heart failure
liver failure
renal failure
hypothyroidism
hypoalbuminaemia
exudative (protein level >30g/L)
infective- pneumonia/ TB/ subphrenic abscess
malignancy - primary lung/ metastatic
connective tissue disease- rheumatoid arthritis, systemic lupus erythematosus
pancreatitis
pulmonary embolism
Dressler’s syndrome
yellow nail syndrome
what causes a haemorrhagic pleural effusion
malignancy, chest trauma, PE, TB
what are the causes of low glucose in pleural fluid
malignancy, empyema, TB, RA, SLE, oesophageal rupture
what are the lights criteria for exudate
lights criteria is used when the pleural protein level is between 25 and 35
exudate is when:
pleural protein: serum protein >0.5
pleural LDH: serum LDH > 0.6
pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
when would you drain a pleural effusion
pH <7.2, frank pus, not amenable to medical management
what are the complications of draining a pleural effusion
pneumonia
pneumothorax
haemothorax
re-expansion pulmonary oedema
what is the composition/ appearance of normal pleural fluid
pH 7.6
protein <1
WCC <1000
LDH <50% serum level
glucose similar to plasma concentration
what are the common conditions for which patients have a lung transplant
single lung transplant- COPD/ bronchiectasis is the most common
double lung transplant- cystic fibrosis/ bronchiectasis
what are the indications of a lung transplant
Patient must have chronic end stage respiratory disease and meet 2 criteria
1) 50% risk of death within 2 years if lung transplant is not performed
2) >80% risk survival at least 90 days post transplant
3) >80% likelihood of 5 year post transplant survival from a medical perspective
what are the complications following a lung transplant
rejection- acute or chronic phase can lead to bronchiolitis obliterans and is the leading cause of death in the first year post transplant
immunosuppresion- malignancy, steroid use, nephrotoxicity, susseptibility to infection
what are contraindications to a lung transplant
malignancy - in the past 5 years
infection- mycobacterium/ burkholdia in the past
organ dysfunction
unsuitability for surgery
what is bronchiectasis
bronchial airway dilation, destruction and inflammation
what are the causes of bronchiectasis
congenital- kartageners, cystic fibrosis
childhood infection- measles, TB
immune overactivity- RA, SLE, IBD
immune underactivity- hypogammaglobinaemia, AIDS
aspiration- GORD/ alcoholics
what are complications of bronchiectasis
pneumonia
pneumothorax
respiratory failure
pulmonary hypertension
what pathogens most commonly affect patients with bronchiectasis
staph aureus
strep pneumonia
Hib
pseudomonas aeruginosa
klebsiella
aspergillus
what do you know about cystic fibrosis
autosomal recessive condition characterised by a defect in the CFTR gene on chromosome 7.
respiratory manifestations are of asthma, bronchiectasis, recurrent infections
GI- malabsorption and pancreatic insufficiency
infertility
what is yellow nail syndrome
disorder characterised by slow growing, curved and thickened yellow nails. Other features include exudative pleural effusions, bronchiectasis, sinusitis and lymphoedema
what are the radiological findings of bronchiectasis
CXR- tramlines and ring shadows
HRCT- signet ring sign- thickened dilated bronchi
what is the management of bronchiectasis
MDT approach
medical- mucolytic therapy- hypertonic saline nebuliser, carbocisteine, bronchodilators, steroids
infections to be treated with a 2 week course- sputum samples
chest PT
annual vaccination- pneumococcal, influenza
smoking cessation
surgery- if not resolving with medical therapy
how to qualify severity of patients COPD by spirometry
obstructive picture therefore FEV1/FVC ratio <0.8
FEV1 compared to predictive number and if >80%- mild
50-80%- moderate
30-50%- severe
<30%- very severe
classes of drugs for COPD
inhaled corticosteroids
SABA/LABA
SAMA/ LAMA
what is cor pulmonale
Right sided heart failure secondary to respiratory disease
chronic hypoxia leads to pulmonary vasodilation and pulmonary hypertension
mainstay of treatment- long term oxygen (16 hours a day), diuretics for congestion
management of long term COPD
rheumatoid related lung diseases
ILD
bronchiectasis
pleural effusions
raised hemidiaphragm (nerve involvement from vasculitis)
obliterans bronchitis
pulmonary nodules (no signs)
UIP vs NSIP
Whilst most connective tissue associated with interstitial lung disease is due to NSIP, in rheumatoid this is not the case and UIP is more common.
UIP is associated more with end stage pulmonary fibrosis and is more difficult to treat than NSIP
which shows more ground glass type changes on HRCT, which is felt to be more associated
with inflammation and potentially reversible with steroids or immunosuppression.
The prognosis of the UIP type interstitial lung disease in rheumatoid arthritis is worse than
NSIP and is similar to that of idiopathic pulmonary fibrosis
