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MRCP PACES > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Things to look for in the hands and wrist in a respiratory exam?

A

Underlying diagnosis:
- Tar staining
- Yellow nails
- Nail fold vasculitis
- Rheumatoid Arthritis
- Sclerodactyly/evidence of systemic sclerosis
- Palmer erythema
- CO2 retention flap
- Wrist tenderness - HPOA
- Small muscle wasting - pancoast tumour
- Gottrons papules - dermatomyositis
- Clubbing

Medications:
- Fine salbutamol tremor
- Thin, bruised skin - steroids

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2
Q

What are some respiratory causes of clubbing?

A

Chronic suppurative lung disease:
- Cystic Fibrosis
- Bronchiectasis
- Empyema
- Abscess

Lung Carcinoma - esp. SCC, not small cell
Pulmonary fibrosis - cryptogenic fibrosing alveolitis
Cryptogenic organising pneumonia
Pleural/mediastinal tumours - mesothelioma

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3
Q

Signs to look for in face in resp exam

A

Eyes:
- pale conjunctiva
- Horners

Face
- Lupus pernio
- Malar rash
- Cushingoid
- Scleroderma features
- Facial swelling

Mouth
- Central cyanosis
- Oral candida
- Microstoma - systemic sclerosis

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4
Q

What does RV heave suggest?

A

Pulmonary hypertension

If feel, remember to palpate P2

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5
Q

Causes of bronchial breathing?

A

Consolidation
Localised fibrosis
Above pleural effusion
Next to large pericardial effusion

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6
Q

If you hear crackles, what is your thought process/what do you do?

A

Disappear on coughing - insignificant.
Move on coughing - bronchiecatasis

Fine + high pitched - distal air space - pulm. oedema/fibrosis

Coarse + low pitched + proximal - bronchiectasis

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7
Q

Completing the respiratory exam?

A

Full set of observations including O2 sats
PEFR + bedside spirometry
ABG

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8
Q

Classic symptoms of pulmonary fibrosis

A

Progressive SOBOE
Dry cough
Malaise/fatigue
Weight loss

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9
Q

What findings would you expect on examination in pulmonary fibrosis?

A

Clubbing
Scars
Reduced chest expansion
Fine late inspiratory crackles which don’t clear on coughing.

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10
Q

Upper Zone Fibrosis?

A

CHARTS
Coal workers
Histiocytosis
Ankylosing Spondylitis/ABPA
Radiation
TB
Silicosis/Sarcoid

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11
Q

Lower Zone Fibrosis?

A

RASIO
Rheumatoid Arthritis
Asbestosis
Scleroderma, SLE, Sjogrens
Idiopathic
Drugs - methotrexate, amiodarone, bleomycin, nitrofurantoin

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12
Q

Underlying causes for pulmonary fibrosis

A

RA

Amiodarone

Connective tissue disease -

Ankylosing spondylitis

Radiation - radiotherapy tattoo/lymphadenopathy

Sarcoidosis

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13
Q

What are the complications of pulmonary fibrosis/bronchiectasis and what are you looking for on examination?

A

Resp Failure
- CO2 flap, cyanosis, accessory muscle use

Cor Pulmonale
- RV heave, raised JVP, peripheral oedema, loud P2

Infection
- Bronchial breathing, fever, Abx at bedside

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14
Q

Signs of RA

A

Peripheral symmetrical deforming polyarthropathy
- swan neck deformity
- z thumb
- ulnar deviation at wrist
- rheumatoid nodules

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15
Q

Signs of amiodarone use

A

Slate grey appearance
Pacemaker
AF
Photosensitivity

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16
Q

Differential Diagnoses for clubbing and crepitations

A

Bronchiectasis - crepitations early and change with coughing + wet cough

Lung Ca - cachexia, tar staining, lymphadenopathy

Abscess

Cystic fibrosis

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17
Q

How is interstitial lung disease classified?

A

Diffuse parenchymla lung disease of known cause:
- Collagen vascular disease
- Occupational/environmental
- Drug related
- Post infection
- Smoking
- Other systemic disorders

Idiopathic interstitial pneumonias
- Idiopathic pulm. fibrosis
- non-specific interstitial pneumonia
- cryptogenic organising pneumonia
- lymphocytic interstitial pneumonia
- acute interstitial pneumonia
- respiratory bronchiolitis-associated interstitial lung disease

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18
Q

What are some asymmetrical causes of pulmonary fibrosis?

A

TB

Malignancy

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19
Q

What investigations would you request for pulmonary fibrosis?

A

Bedside:
- ECG - ?Right heart strain
- ABG - ?respiratory failure

Bloods:
- FBC - eosinophilia, anaemia, polycythaemia
- CRP/ESR
- Immunoglobulins
- Complement
- Autoimmune screen - ANA, ANCA, RF, anti CCP, CK, anti GBM
- Serum precipitins - hypersensitivity pneumonitis
- Serum ACE - sarcoid

Imaging
- CXR
- High res CT
Look for Bilateral reticulonodular interstitial infiltrates, ground glass changes, honeycombing and volume loss

Special Tests
- Lung function tests
- Bronchoalveolar lavage
- Biopsy - video assisted, open or transbronchial
- Echo - ?Pulm HTN

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20
Q

How is pulmonary fibrosis managed conservatively?

A

Stop smoking
Remove causative allergen/medication
Vaccines - influenza + pneumococcal
Compensation if asbestos
Pulm. rehab

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21
Q

What is the medical management of pulmonary fibrosis?

A

Treat underlying cause

Manage complications - infections, pulm HTN, lung Ca, resp failure

Steroids

Immunosuppressants - azathioprine, cyclophosphamide

Pirfenidone - antifibrotic and antiinflammatory

Antioxidants - N acetylcysteine

LTOT

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22
Q

What is the surgical management of pulmonary fibrosis?

A

Single or double lung transplant

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23
Q

How would a single lung transplant patient due to pulmonary fibrosis present?

A

Unilateral fine crackles

Contralateral thoracotomy scar with normal breath sounds

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24
Q

What are the indications for bronchoalveolar lavage in pulmonary fibrosis?

A

Exclude infection prior to immunosuppression

Also, if BAL Lymphocytes>neutrophils - indicate better response to steroids and better prognosis

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25
Q

What is the prognosis of pulmonary fibrosis?

A

Around 80% 5 year survival

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26
Q

What is the commonest form of idiopathic pulmonary fibrosis?

A

Usual interstitial pneumonia - show subpleural distribution on HRCT

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27
Q

What is bronchiectasis?

A

Abnormal, permanent thickening and dilatation of the bronchi and bronchioles due to:

  • repeated infection
  • impaired drainage
  • airway obstruction
  • +- defective host response
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28
Q

How does Bronchiectasis present?

A

SOB
Chronic, thick purulent cough
Haemoptysis
Recurrent Infections
Pleuritic chest pain
Weight loss
History of childhood infections, sinusitis, subfertility

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29
Q

Key examination features for bronchiectasis

A

Purulent sputum in pot
Inhalers at bedside

Clubbing
Scars on chest
Reduced chest expansion

Early, coarse creps which alter with coughing

Wheeze

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30
Q

Underlying causes of bronchiectasis

A

Post infective:
- Bacterial - pertussis/TB
- Viral - measles, HIV
- ABPA
- Recurrent Aspiration

Congenital Mucociliary Clearance Defects:
- Cystic fibrosis
- Kartageners

COPD

Immunodeficiency
- HIV, hypogammaglobulinaemia

Mechanical
- Foreign body, carcinoma, lymph node, granuloma

Connective tissue disorder
- RA
- SLE

Others:
- Yellow nail syndrome
- Youngs - mercury intoxification and infertility
- IBD
- Congenital kyphoscoliosis
- Idiopathic

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31
Q

Signs of kartageners syndrome?

A

Dextrocardia

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32
Q

Signs of yellow nail syndrome

A

Yellow Nails
Lymphoedema

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33
Q

Signs of treatment for bronchiectasis

A

Steroids - cushingoid, bruising, thin skin, proximal myopathy

Oxygen

Scars - lung surgery

Inhalers, nebulisers, Abx

34
Q

How is severity of bronchiectasis determined?

A

MRC dyspnoea scale - >4
Number of bronchopulmonary segments involved
Lung function assessment

35
Q

How is bronchiectasis investigated?

A

Bedside - ABG + ECG

Lab
- FBC - WCC, anaemia, eosinophilia
- CRP
- Immunoglobulins - low in hypogammoglobulinaemia
- Autoimmune - ANA, RF, anti CCP
- HIV
- Aspergillus precipitins and IgE - ABPA
- Quantiferon

  • Sputum MC&S

Imaging
- CXR
- HRCT

Special
- Lung function - obstructive
- Biopsy - ?malignancy - video assisted, transbronch, open
- Echo - ?Pulm HTN
- CF sweat test/genotyping
- Cilia studies

36
Q

CXR findings for bronchiectasis?

A

Tramlines - diseased bronchi side on
Ring shadows - diseased bronchi end on
Gloved finger - mucoid impactions in large airways
Hyperinflation

7% are normal

37
Q

HRCT findings for bronchiectasis

A

Signet ring sing - thickened end on dilated bronchi >1.5x adjacent pulm. artery

Tram tracking
Ring shadows
Volume loss
Flame and blob sign - mucous plugging

38
Q

Conservative mx of bronchiectasis

A
  • Stop smoking
  • Vaccines - haemophilus, influenza, pneumococcus
  • Resp. physio - Postural drainage and insp. muscle training
  • Optimise nutrition
39
Q

Medical mx of bronchiectasis

A

Treat cause - immunoglobulins if low
Mucolytics
Bronchodilators - inhaled/nebulised
Prophylactic antibiotics - PO, IV or Nebulised
Steroids
Manage complications
Azithromycin - anti-inflammatory

40
Q

Surgical Mx of bronchiectasis

A

Lung transplant - cystic fibrosis

Lobectomy/Bullectomy for localised disease

Bronchial artery embolisation if massive haemoptysis

41
Q

Common complications of bronchiectasis

A

Pulmonary:
- Recurrent infection
- Haemoptysis - can be massive (>400mls)
- Empyema/Abscess
- Cor Pulmonale
- Pneumothorax/lung collapse

Extra-pulmonary
- Anaemia
- Cerebral abscess
- Secondary amyloidosis

42
Q

Pathogens associated with bronchiectasis

A

Common:
- Pseudomonas
- Haemophilus influenza
- Streptococcus

Others
- Staph aureus
- Moraxella
- ABPA

Concerning
- Burkholderia in CF
- Mycobacterium

43
Q

How is Kartageners Syndrome Inherited?

A

Autosomal Recessive

A type of primary ciliary dyskinesia

44
Q

What is Kartageners Syndrome

A

Dextrocardia - situs inversus

Sinusitis

Bronchiectasis

45
Q

What is the pathophysiology of cystic fibrosis?

A

Autosomal recessive disease
Defect of CFTR gene on Chromosome 7
Most common mutation is delta F508

Defective CFTR means thick viscous secretions –> colonisation, infection and blockages of lumens

46
Q

What are the features of CF?

A

GI - DIOS
Pancreas - Pancreatic insufficiency –> protein and fat malabsorption
Diabetes
Gallstones
Biliary cirrhosis –> Portal HTN
Subfertility - men
Sinus disease and nasal polyps
Osteoporosis
Bronchiectasis

47
Q

What organisms commonly colonise CF patients

A

Staph aureus
Haemophilus Influenzae
Pseudomonas
Burkholderia cepacia - worst prognosis - poss CI to transplant

48
Q

What things to look for in resp exam if ?cystic fibrosis

A

Young, short, thin
Clubbing
PEG feed
Long term vascular device

If long station - ask about GI/endocrine

49
Q

What is the prognosis for CF?

A

Mean survival 32 years and increasing

Many survive into 40s

50
Q

Possible causes for pleural effusion?

A

Malignancy
Infection
CCF
Chronic Liver Disease
CKD
Connective Tissue Disease
Sarcoidosis
Yellow Nail Syndrome
Dressler’s
PE

51
Q

Signs to look for ?lung malignancy

A

Clubbing
Cachexia
Lymphadenopathy
Tar staining
Radiation burns
Horners - pancoast
Small hand muscle wasting - Pancoast
HPOA - wrist tenderness, clubbing - Adenocarcinoma
Evidence of Chemo - hair loss
Scars - resection/mastectomy

52
Q

Signs to look for ?chest infection

A

Chest drain scar
IV cannula
IV abx
Febrile

53
Q

Signs to look for CCF

A

Raised JVP
Sacral oedema
Peripheral oedema
Bibasal creps

54
Q

Signs to look for CKD

A

AV fistula
Peritoneal dialysis
CBG monitoring marks
Renal biopsy scar
Scar from neck lines

55
Q

Connective tissue diseases associated with pleural effusion

A

Lupus
Systemic sclerosis
Rheumatoid arthritis

56
Q

Signs to look for ?yellow nail syndrome

A

Yellow nails
Lymphoedema
Features of bronchiectasis

57
Q

Signs for ?Dresslers in pleural effusion

A

CABG scar

58
Q

Differential Diagnoses for pleural effusion

A

Lower lobe collapse
Lobectomy - look for scar
Raised hemidiaphragm - phrenic nerve palsy/hepatomegaly
Basal consolidation
Pleural thickening - plaques
Mitotic mass

59
Q

Signs of pleural effusion on examination

A

Reduced expansion
Tracheal deviation away
Apex beat shift away
Stony dull to percuss
Reduced vocal resonance
Reduced air entry/breath sounds
Bronchial breathing above

60
Q

What is Lights Criteria

A

1 out of 3 = exudate

1 Pleural albumin/serum albumin >0.5
2 Pleural/Serum LDH >0.6
3 Pleural LDH >2/3 upper normal limit of serum LDH

61
Q

How would you differentiate between a transudate or exudative pleural effusion

A

protein >30g/dl - exudate
Protein <30g/dl - transudate

62
Q

Causes of transudative pleural effusion

A

CCF
Cirrhosis
Nephrotic syndrome
Hypoalbuminaemia
Meig’s syndrome
Myxoedema

63
Q

Causes of exudative pleural effusion

A

Malignancy - bronchial/pleural/secondary
Infection - parapneumonic, TB - can cause empyema
PE
Sarcoid
Connective tissue disease
Pancreatitis
Dresslers
Drugs - nitro, methotrexate, amiodarone, phenytoin
Yellow nail syndrome
Asbestos
Oesophageal rupture

64
Q

Where can secondary lung malignancies commonly come from

A

Breast
Renal
Pancreas
Ovaries

65
Q

How would you approach a patient with a lateral thoracotomy scar?

A

Any rib resection - ?TB in past - look for phrenic nerve crush scar, kyphosis, apical fibrosis

Is underlying lung normal?
- Lobectomy + transmitted sounds/re-expansion
- Bullectomy
- Lung transplant
- Pleurectomy
- Open lung biopsy

Abnormal underlying lung?
- Lobectomy
- Pneumonectomy
- Lung volume reduction surgery
- Bullectomy with ongoing poorly controlled COPD
- Lung transplant with complications

66
Q

What should you comment on when a patient has a lateral thoracotomy scar?

A
  • Side of scar
  • Chest asymmetry - flattening
  • Tracheal deviation
  • Chest expansion
  • Apex beat - ?displaced
  • Percussion - dull if pneumonectomy
  • Breath sounds - reduced
  • Vocal resonance - reduced
  • Creps/wheeze

Evidence of resp failure

Try to determine cause

67
Q

What are some reasons a patient may have a thoracotomy scar?

A

Lung Cancer
Bronchiectasis
Pulmonary AV malformation - part of HHT
COPD
TB Thoracoplasty

68
Q

What signs may you see with a patient with a lobectomy?

A

Lateral thoracotomy scar
VATS scar
Trachea usually central - can be displaced in upper lobectomy
Apex beat may be displaced
Percussion/Auscultation may be normal due to compensatory hyperinflation

69
Q

What signs may you see with a patient with a lobectomy?

A

Lateral thoracotomy scar + flattened chest on operated side
Trachea deviated
Reduced chest expansion
Apex beat to side of op
Dull to percussion
Reduced breath sounds - may hear transmitted sounds

70
Q

What signs may you see with a patient with a lung transplant?

A

Lateral thoracotomy/Clamshell scar - clamshell if double
Intercostal drain sites
Median sternotomy scar - single lung/heart+lung
Medication signs

If single - assess for underlying cause in opposite lung
If double - may be normal. Assess for failure

71
Q

What are some indications for lobectomy/pneumonectomy?

A

Lung cancer - mostly non small cell
Solitary pulmonary nodules
Localised bronchiectasis - with infections/haemoptysis
Lung abscess
TB

72
Q

What are some indications for lung transplant?

A

COPD
Alpha 1 antitrypsin
Pulmonary fibrosis
Bronchiectasis
Pulmonary HTN
Cystic Fibrosis

73
Q

What are the complications of lung transplant?

A

Infection
- HSV and CMV
- Bacterial
- Mycobacterial

Rejection
- Very common - most experience in first 6 months

Immunosuppression
Malignancy - post-transplant lymphoproliferative + skin
Bronchiolitis Obliterans
Medication related - inc. renal and hearing impairment

74
Q

What is bronchiolitis obliterans?

A

Inflammation and scarring of bronchioles
Cause fine late inspiratory creps
Eventually leads to resp. failure

75
Q

When is a double transplant usually done over a single lung transplant?

A

Double prognosis is usually better.
Double - CF and bronchiectasis
Single - COPD/ILD - generally poorer prognosis

However as prognosis is better, double becoming more common

76
Q

What are some criteria to list patients for transplant?

A
  • > 50% risk of death in 2 years if transplant not performed
  • > 80% likelihood of surviving >90 days post transplant
  • > 80% 5 year post transplant survival from gen med perspective
77
Q

What are the absolute contraindications to lung transplant?

A
  • Malignancy in past 5 years or last 2 years if low chance of recurrence e.g. Skin BCC
  • Untreatable heart, liver, kidney, brain dysfunction - unless combined transplant
  • Untreated atherosclerosis with end organ damage or coronary artery disease which is untreatable
  • Acute illness - Sepsis, MI, liver failure
  • Chronic infection - virulent or resistant and poorly controlled on therapy
  • Mycobacterium infection in CF
  • Significant chest wall deformity
  • Obese - BMI >35
  • Non adherence to therapy
  • Severely impaired functional status
  • No social support system
  • Substance abuse - inc. smoking or dependence
78
Q

What are some relative CIs to lung transplant

A

BMI >30
Resistant organisms - burkholderia
Age >65
Severe osteoporosis
Severe malnourished

79
Q

When would patients be listed for lung transplant?

A

Can be done early - e.g. all patients with NSIP or usual interstitial pneumonia

Doesn’t mean transplant is immediate but can be worked up so can be done in timely manner.

Consider with sudden deterioration e.g. FVC >10% drop in 6 months

CF - FEV1<30% + poor exercise tolerance, Pulm HTN, instability of condition, pneumothoraces etc.

COPD - BODE index >7

80
Q

What medications are used in lung transplant?

A

Lifelong immunosuppression

Combination of:
- Pred
- Calcinurine inhibitor - cyclosporin or tacrolimus
- Nucleotide blocking - azathioprine or mycophenolate

Prophylactic meds for opportunistic infections

MRCP PACES (6 decks)

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