Respiratory Flashcards
Contraindications for lung transplant in CF
Burkholderia cepacia colonised in sputum
Mycobacterium
Light’s criteria
Used if fluid protein 25-35
Pleural protein: serum protein >0.5
Pleural LDH: Serum LDH >0.6
Pleural LDH >2/3 ULN serum LDH
Indications for VATS
Pleural or lung biopsy
Pleurodiesis
Pleurectomy
Empyema treatment
Pericardiocentesis
Mutations in CF
Mutations in CFTR excretion - more salt excretion in mucus
Most common deltaF508
Specific treatment for deltaF508
Ivacaftor and Orkambi
Surgical treatment in COPD
Lung reduction surgery
Lung transplant
Indications for LTOT in COPD
Pa02 <8kpa with evidence of pulmonary hypertension, polycythaemia or peripheral oedema
Pa02 <7.3kPa
No smoking in household
Long term treatment in COPD
Smoking Cessation
Pulmonary rehab
Vaccinations - flu/COVID/pneumococcal
Inhaler therapy - LABA/LAMA or adding ICS if eosinophilia or repeated infections
LTOT
Contraindications to NIV
Capacitous refusal
Facial fractures
Oesophageal burns
Vomiting
Pneumothorax
Airway obstruction
Pneumothorax
Hypotension
Recent upper GI surgery
Spirometry values in COPD
Diagnosis - FEV1/FVC <70%
Mild >80%
Moderate - FEV1 50 - 80%
Severe - FEV1 30-50%
Very evere - <30%
Increased residual volume
Decreased TLCO
Investigations in new COPD
FBC - anaemia, polycythaemia and eosinophilia
IGE to aspergillus and dog/cat dander
A1AT deficiency if young
ABG
CXR
CT - emphysema and bulls lung disease
Spirometry with reversibility testing
ECHO if concerns re PHTN
Differential diagnoses for COPD
Asthma
EGPA
A1AT
Signs of pulmonary hypertension
Raised JVP
Pulsatile liver
Loud second heart sound
Pedal oedema
Tricuspid regurgitation
Clinical findings in COPD on inspection
Barrel Chested
Tar staining
Pursed lips
Tremor
Central cyanosis
Raised JVP in cor pulmonate
Signs in bronchiectasis
Wet cough
Clubbing
Long lines and central access
Cachexia
Scars from previous lines or lung surgery
Clamshell scar under the ribcage
Deviated apex beat and loud P2
Wet coarse crackles at bases - change with coughing
Presentation in bronchiectasis
Signs of right sided heart failure - raised JVP, pedal oedema, loud P2
Signs of treatment - neb or iv antibiotics
Scars from lung transplant
Possible etiology
Causes of bronchiectasis
Congenital
- Kartageners - dextracardia
- CF
Yellow nail syndrome
Post infectious eg tb, childhood pneumonias (pertussis)
Autoimmune
- RA
- lupus
- sjogrens
- IBD
Immunodeficiencies:
- Hypogamma globulinaemia
- CVID
- HIV
ABPA
Aspiration - chronic alcoholics, post stroke
Ix in bronchiectasis
CXR - tramlines and ring shadows
HRCT - signet rings, tram lines, tree in bud appearance, inner lumen bigger than adjacent blood vessel
Bloods
- HIV test
- Autoimmune screen
- Immunoglobulin
- IgE aspergillus
- eosinophilia
Sputum samples
Sweat test and ciliary biopsy in CF
Saccharine motility tes
Lung function tests
- Reduced FEV1 - obstructive due to inflamed or scarred airways
Echo if concerns re pulmonary hypertension
Mx in bronchiectasis
MDT
Patient education
Identify cause
Chest physio - postural chest drainage
Hypertonic saline nebs
Targeted antibiotic therapy
Carbocisteine
Opep device - flutters and breaks up mucus
Immunization
Dietician
Prophylaxis antibiotics
- if having more than two chest infections which have been fully treated
- dependent on sensitivities
- may be oral or nebulised (eg PO azithromycin or Neb tobramycin)
Ix in ILD
Bedside test inc SpO2
Bloods including Rhf, anti-CCP, ANA, ANCA, dsDNA
ABG
CXR
HRCT
- Honeycombing - fibrosis
- Ground glass shadowing - alveoli’s
ECHO - signs of pulmonary hypertension
Spirometry
Potential biopsy - unclear diagnosis - via bronchoscopy or trans lung
Spirometry findings in ILD
Restrictive pattern
Decrease in FEV1 and FVC with preserved ratio
Reduced TLC
Decrease in transfer factor
MX of ILD
MDT
Resp nurses
PT and OT
Treatment of underlying CTD
Steroids
Idiopathic ILD - anti-fibrotic agents
- Pirfenedone or ninetenib - its with a FVC 50-80% to slow disease progression
NSIP - steroids and immunosuppressive therapy
Lung transplant
Causes of ILD
Idiopathic
RA
SLE
Asbestosis
Drugs - bleomycin, amiodarone, MTX, nitrofurantoin
AS
Radiation
Coal workers pneumoconiosis
Silicosis
EAA
Sarcoidosis
TB
Features in CF
Increased and thickened respiratory secretions
Pancreatic insufficiency
Decrease in fertility
Liver disease - portal HTN
Osteopenia
Nasal polyps
Distal intestinal obstruction syndrome
Gallstones and kidney stones
Management in CF
MDT in specialist centre
Chest physio
Nebulised hypertonic saline
Mucolytics
Nebulised prophylactic antibiotics
Creon
Dietician
Nutritional supplementation
Treatment of infection with 2 week course of antibiotics
Fat soluble vitamin supplementation
Immunisations
Diagnosis of CF
Screening with Guthrie test
Episode of meconium ileus
Sweat test
Genetic testing
Commonest indicator conditions for lung transplantation
CF
Bronchiectasis
ILD
Pulmonary vascular disease
COPD
Double vs single lung transplant
Prognosis better with double lung transplant - 7.5 vs 4 years
Medications used in lung transplantation
Combination of tacrolimus, MMF and steroids
Complications of lung transplant
Hyperacute/acute rejection
Opportunistic infections
Brochiolitis obliterates - chronic rejection - 50% at 5 years
Increased risk of malignancy including post transplant lymphoproliferative disease and skin malignancies
Contraindications to lung transplantation
Malignancies within last 5 years
Untreatable heart, brain or liver dysfunction that won’t be treated with transplant
Untreated atherosclerotic disease or CAD not amenable to revascularisation
High or low BMIs
Using illicit drugs or smoking
Mental health issues which would stop them taking regular meds or turning up to clinic appts
Virilent lung pathogens including Burkholderia cepacia or mycobacterium
Indications for single lung transplant
COPD
ILD
Indications for lung transplant
> 50% risk of death from lung condition within 2 years without transplant
80% chance of survival 90 days post transplant
80% chance of 5 year survival from general medical viewpoint
Indications in CF for lung transplant
FEV1 <30%
Significant pHTN
Poor exercise tolerance
High exacerbation frequency
Frequent PTXs
Haemoptysis despite pulmonary artery embolisation
NIV
Indications in ILD of lung transplant
Due to poor prognosis - fibrotic NSIP with no contraindications should be considered
FVC <80%
Transfer factor <40%
Any oxygen requirement or symptomatic dyspnoea
Scores for high risk vs low risk PE treatment
PESI or sPESI - Class I and II
Anticoagulation treatment for PE
Provoked PE - 3 months
Unprovoked - 3-6 months
Management of unstable PE patients with contraindication for thrombolysis
Surgical vs mechanical thrombectomy
Methods of gaining a lung biopsy
Bronchoscopy
EBUS
Percutaneous
LN FNA
Pleural aspirate cytology
Different types of lung cancer
Small cell and NSCLC
NSCLC - SCC, adenocarcinoma, large cell tumours, neuroendocrine, and bronchoalveolar
Treatment of SCLC
Usually aren’t amenable to surgery at diagnosis - aggressive
Chemotherapy regimens - platinum based with radiotherapy +/- adjuvant brain radiation in limited disease
Treatment of NSCLC
Surgery or radical radiotherapy (stage I and II disease)
Chemotherapy/immunotherapy
TKI - e.g erlotinib (EGFR) or alectinib (ALK)
Clinical signs in lung cancer
Finger clubbing - HPOA
Wasting of small muscles in hand
Cachexia
Hoarseness of voice
Tar staining
Horner syndrome - ptosis, miosis and facial swelling
Dilated chest wall veins and facial swelling
Radiotherapy tattoos
VATS scars
Thoracotomy scar
Reduced expansion or reduced air entry if collapse or surgical excision
Tracheal deviation - away from pleural effusion, towards collapse
Lymphadenopathy
Causes of pleural effusions
Exudative effusions:
- Parapneumonic
- Tb
- Empyemas
- Malignancy
- CTD e.g. RA and sarcoid
Transudative:
- HF
- Liver failure
- Chronic kidney disease
- Hypoalbuminaemia
- Hypothyroidism
Pleural aspirate sendaways
Protein
LDH
pH
Culture
Cell count
Cytology
Glucose - if ?RA
Triglyceride - if suspected chylous
Pleural effusion treatment
Drainage indicated if pH <7.2, frank pus or positive cultures
If not symptomatic management and drainage only if needed
If due to underlying malignancy can have an indwelling drain or pleurodiesis
Ix in pleural effusions
FBC, U&Es, LFTs, Ca, Coag
CXR
Pleural samples
CT thorax with contrast
Pleural biopsy - medical thoracoscopy
Indications for lung surgery in lung cancer
Stage I or II disease, or selected stage III disease without mediastinal lymph node involvement
Lobectomy:
- FEV1 >1.5L
Pneumonectomy:
- FEV1 >2L
Will also need CPET - 15ml/kg/min
Indications of thoracotomy
LL/UL lobectomy
Pneumonectomy
Wedge resection
Open lung biopsy
Bullectomy
Previous trauma
Indications for lobectomy/pneumonectomy
Malignancy - NSCLC or malignant nodule
Lung Abscess
Localised bronchiectasis
TB
Lung trauma
Indications for VATS
Lung biopsy
Pleural procedures
Lobectomy
Mechanism of cor pulmonae in COPD
Chronic hypoxia
Pulmonary vasoconstriction
Pulmonary hypertension
Right side cardiac failure
Causes of apical pulmonary fibrosis
Tb
Radiation
Ankylosing spondylitis/ABPA
Sarcoidosis
Histoplasmosis/histiocytosis/pneumonitis
Coal worker’s pneumoconiosis
Berylliosis
Silicosis
Side effects of Tb medications
Isoniazid - peripheral neuropathy (co-prescribe pyridoxine)
Rifampicin - Hepatitis and enzyme induced (careful of COCP)
Ethambutol - retrobulbar neuritis and hepatitis
Pyrazinamide - hepatitis
Clinical differences between lobectomy and pnuemonectomy
Lobectomy:
- Breath sounds present
- May have some dullness to percussion or hyper resonance at base or apex depending on which lobe was resected
- Trachea central
Pneumonectomy:
- Breath sounds absent (may have bronchial breathing at apex)
- Dull percussion note throughout hemithorax
- Trachea pushed towards side of pneumonectomy
Indications for single lung transplant
COPD, ILD (Dry conditions)
Thoracotomy scar, may have clinical signs on opposite hemithorax
Indications for double lung transplant
Bronchiectasis (including CF), pulmonary hypertension
Clamshell scar
Classification of severity in COPD
Classified by GOLD framework using FEV1
Mild - >80%
Mod - 50-80%
Severe - 30-50%
Very severe - <30%
Differentials for wheeze on auscultation
COPD
- Smoking/industrial
- A1AT
Asthma
GPA
Obliterative bronchiolitis - seen in RA and in post transplant lung
Surgical treatments in COPD
Bullectomy - if bulla >1L and causing compression on surrounding lung
Endobronchial valve
Lung reduction surgery
Lung transplant - usually single
Spirometry findings in COPD
Reduced FEV1
FEV1:FVC ration <0.7
Reduced TLCO
Causes of pleural effusions
Trasnudative (<30g/L protein):
- CCF
- Cardiac failure
- Chronic liver failure
Exudative >30g/L protein;
- Infection either parapneumonic or empyema
- Cancer
- Inflammatory condiitons e.g. RA, SLE
- Pulmonary infarction
Causes of a dull lung base
Pleural effusion
Consolidation in infection
Raised hemidiaphragm
Lobectomy
Pleural thickening
Complications seen in lung cancer
SVCO - Bronchial cancers causing facial swelling and dilated chest veins
Hypercalcamia - mostly commonly in SCC (secretion of PTHrp or in mets)
Recurrent laryngeal nerve palsy
Horner’s syndrome - seen in Pancoast tumours
MSCC
Cushing’s disease - Most commonly in SCLC - with ectopic ACTH secretion
SAIDH - most commonly in SCLC
Lambert-Eaton syndrome - most commonly in SCLC - VGCC abs presents
Dermatomyositis - Gouttrons papule, heliotrope rash and raised CK
Types of lung cancer
SCLC - 25%
NSCLC:
- SCC - 35%
- adenocarcinoma - 20%
- Large cell - 20%
- Alveolar
Additional tests for organisms in pneumonia
Legionella antigen (may also be hyponatraemic)
Pneumococcal antigen
Haemoglobinuria - mycoplasma causes cold agglutinins leading to haemolysis
Causes of CAP
Strep pneumonia
Mycoplasma pneumonia
Haemophilusinfluenza
Chalmydia pneumonia
Post influenza - S aureus
Immunosuppressed;
- Fungal
- PCP - treat with co-trimoxazole
CURB65 score
Confusion
Urea >7
Respiratory rate >30
BP <90 systolic or <60 diastolic
>65
2/5 is severe and should receive IV abs
Complications of CAP
Parapneumonic effusion
Empyema
Haemoptysis
Sepsis
Investigation of Pulmonary Hypertension
Bloods:
- Autoimmune screen)
- TFTs
- Liver function (porto-pulmonary PH)
- HIV
CXR
ECG
ECHO - looking for right ventricular size and function, peak tricuspid regurgitant velocity to estimate pulmonary pressure
CTPA - chronic thrombi
PFTs
Right heart catheterisation
Causes of Pulmonary Hypertension
Class I: Pulmonary arterial hypertension - idiopathic, heritable, CTD, congenital heart disease, portal hypertension, HIV
Class II: Left heart disease: systolic or diastolic dysfunction or valvular disease
Class III: Lung disease: COPD, ILD, obesity hypoventilation, sarcoidosis
Group IV: Chronic thromboembolic disease
Group V: miscellaneous - harm-dialysis, thyrotoxicosis
Treatment in Pulmonary Hypertension
Group 1 (PAH):
- CCBs - nifedipine - only in those responsive to vasodilator challenge during right heart catheterisation
- Phophodiesterase 5 inhibitors - sildenafil
- Endothelin receptor antagonists - bosentan, ambrisentan
- Prostaglandin analogues - epoprostenol (IV infusion) or Neb iloprost
Double lung transplant
Group 4 (chronic thromboembolic disease):
- Life long anticoagulation
- Pulmonary endarterectomy surgery if proximal
If distal balloon pulmonary angioplasty
Group 2,3, and 5 - treat underlying cause
Complications of Pulmonary Hypertension
Right heart failure
Atrial arrhythmias
Dilatation of the proximal pulmonary artery - stretching of the recurrent laryngeal nerve - voice hoarseness
External compression of the the LAD - angina type symptoms and ventricular arrhythmias
External compression of the RML bronchus - localised bronchiectasis
