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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
What is the prognosis of pulmonary fibrosis?
Around 80% 5 year survival
26
What is the commonest form of idiopathic pulmonary fibrosis?
Usual interstitial pneumonia - show subpleural distribution on HRCT
27
What is bronchiectasis?
Abnormal, permanent thickening and dilatation of the bronchi and bronchioles due to: - repeated infection - impaired drainage - airway obstruction - +- defective host response
28
How does Bronchiectasis present?
SOB Chronic, thick purulent cough Haemoptysis Recurrent Infections Pleuritic chest pain Weight loss History of childhood infections, sinusitis, subfertility
29
Key examination features for bronchiectasis
Purulent sputum in pot Inhalers at bedside Clubbing Scars on chest Reduced chest expansion Early, coarse creps which alter with coughing Wheeze
30
Underlying causes of bronchiectasis
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
31
Signs of kartageners syndrome?
Dextrocardia
32
Signs of yellow nail syndrome
Yellow Nails Lymphoedema
33
Signs of treatment for bronchiectasis
Steroids - cushingoid, bruising, thin skin, proximal myopathy Oxygen Scars - lung surgery Inhalers, nebulisers, Abx
34
How is severity of bronchiectasis determined?
MRC dyspnoea scale - >4 Number of bronchopulmonary segments involved Lung function assessment
35
How is bronchiectasis investigated?
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
CXR findings for bronchiectasis?
Tramlines - diseased bronchi side on Ring shadows - diseased bronchi end on Gloved finger - mucoid impactions in large airways Hyperinflation 7% are normal
37
HRCT findings for bronchiectasis
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
Conservative mx of bronchiectasis
- Stop smoking - Vaccines - haemophilus, influenza, pneumococcus - Resp. physio - Postural drainage and insp. muscle training - Optimise nutrition
39
Medical mx of bronchiectasis
Treat cause - immunoglobulins if low Mucolytics Bronchodilators - inhaled/nebulised Prophylactic antibiotics - PO, IV or Nebulised Steroids Manage complications Azithromycin - anti-inflammatory
40
Surgical Mx of bronchiectasis
Lung transplant - cystic fibrosis Lobectomy/Bullectomy for localised disease Bronchial artery embolisation if massive haemoptysis
41
Common complications of bronchiectasis
Pulmonary: - Recurrent infection - Haemoptysis - can be massive (>400mls) - Empyema/Abscess - Cor Pulmonale - Pneumothorax/lung collapse Extra-pulmonary - Anaemia - Cerebral abscess - Secondary amyloidosis
42
Pathogens associated with bronchiectasis
Common: - Pseudomonas - Haemophilus influenza - Streptococcus Others - Staph aureus - Moraxella - ABPA Concerning - Burkholderia in CF - Mycobacterium
43
How is Kartageners Syndrome Inherited?
Autosomal Recessive A type of primary ciliary dyskinesia
44
What is Kartageners Syndrome
Dextrocardia - situs inversus Sinusitis Bronchiectasis
45
What is the pathophysiology of cystic fibrosis?
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
What are the features of CF?
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
What organisms commonly colonise CF patients
Staph aureus Haemophilus Influenzae Pseudomonas Burkholderia cepacia - worst prognosis - poss CI to transplant
48
What things to look for in resp exam if ?cystic fibrosis
Young, short, thin Clubbing PEG feed Long term vascular device If long station - ask about GI/endocrine
49
What is the prognosis for CF?
Mean survival 32 years and increasing Many survive into 40s
50
Possible causes for pleural effusion?
Malignancy Infection CCF Chronic Liver Disease CKD Connective Tissue Disease Sarcoidosis Yellow Nail Syndrome Dressler's PE
51
Signs to look for ?lung malignancy
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
Signs to look for ?chest infection
Chest drain scar IV cannula IV abx Febrile
53
Signs to look for CCF
Raised JVP Sacral oedema Peripheral oedema Bibasal creps
54
Signs to look for CKD
AV fistula Peritoneal dialysis CBG monitoring marks Renal biopsy scar Scar from neck lines
55
Connective tissue diseases associated with pleural effusion
Lupus Systemic sclerosis Rheumatoid arthritis
56
Signs to look for ?yellow nail syndrome
Yellow nails Lymphoedema Features of bronchiectasis
57
Signs for ?Dresslers in pleural effusion
CABG scar
58
Differential Diagnoses for pleural effusion
Lower lobe collapse Lobectomy - look for scar Raised hemidiaphragm - phrenic nerve palsy/hepatomegaly Basal consolidation Pleural thickening - plaques Mitotic mass
59
Signs of pleural effusion on examination
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
What is Lights Criteria
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
How would you differentiate between a transudate or exudative pleural effusion
protein >30g/dl - exudate Protein <30g/dl - transudate
62
Causes of transudative pleural effusion
CCF Cirrhosis Nephrotic syndrome Hypoalbuminaemia Meig's syndrome Myxoedema
63
Causes of exudative pleural effusion
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
Where can secondary lung malignancies commonly come from
Breast Renal Pancreas Ovaries
65
How would you approach a patient with a lateral thoracotomy scar?
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
What should you comment on when a patient has a lateral thoracotomy scar?
- 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
What are some reasons a patient may have a thoracotomy scar?
Lung Cancer Bronchiectasis Pulmonary AV malformation - part of HHT COPD TB Thoracoplasty
68
What signs may you see with a patient with a lobectomy?
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
What signs may you see with a patient with a lobectomy?
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
What signs may you see with a patient with a lung transplant?
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
What are some indications for lobectomy/pneumonectomy?
Lung cancer - mostly non small cell Solitary pulmonary nodules Localised bronchiectasis - with infections/haemoptysis Lung abscess TB
72
What are some indications for lung transplant?
COPD Alpha 1 antitrypsin Pulmonary fibrosis Bronchiectasis Pulmonary HTN Cystic Fibrosis
73
What are the complications of lung transplant?
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
What is bronchiolitis obliterans?
Inflammation and scarring of bronchioles Cause fine late inspiratory creps Eventually leads to resp. failure
75
When is a double transplant usually done over a single lung transplant?
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
What are some criteria to list patients for lung transplant?
- >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
What are the absolute contraindications to lung transplant?
- 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
What are some relative CIs to lung transplant
BMI >30 Resistant organisms - burkholderia Age >65 Severe osteoporosis Severe malnourished
79
When would patients be listed for lung transplant?
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
What medications are used in lung transplant?
Lifelong immunosuppression Combination of: - Pred - Calcinurine inhibitor - cyclosporin or tacrolimus - Nucleotide blocking - azathioprine or mycophenolate Prophylactic meds for opportunistic infections
81
Symptoms of TB?
Fever Weight loss Night sweats Haemoptysis Productive cough SOB Pleuritic chest pain
82
Signs on inspection for old TB?
Cachexia Chest wall deformity - rib resection Orange urine - rifampicin Thoracotomy scar Supraclavicular scar - phrenic nerve crush scar Chest drain scar Kyphosis - spinal TB
83
Signs on examination of old TB?
Tracheal deviation towards old TB Displaced apex beat Reduced expansion Dull to percussion Reduced breath sounds Crepitations - can get fibrosis and bronchiectasis Bronchial breathing
84
Investigations for suspected TB?
Bloods: - FBC, UE, CRP, LFT (pre-treatment) - HIV screen - Hep B/C Sputum - MC&S, Ziehl Neelson stain 3x AFB sputum culture Early morning urine AFB Mantoux - can be negative if immunosuppressed Quantiferon Imaging: - CXR - ghon focus, cavitations, pleural effusions, pulm. nodules, pneumothorax, lobe collapse, consolidation - CTAP - UL fibrosis, traction bronchiectasis, pleural scarring Bronchoscopy - BAL Extra pulmonary biopsy - LN
85
How is TB Managed?
Rifampicin, Isoniazide, Pyrazinamide, Ethambutol 2 months of all 4 then 4 months of Rifampicin and Isoniazid alone Notifiable disease
86
ADR's of TB drugs
Drug induced hepatitis - rifampicin, isoniazid, pyrazinamide Optic neuritis - ethambutol Peripheral neuropathy - isoniazid -> co prescribe pyridoxine
87
What are the old surgical techniques for managing TB?
Phrenic nerve crush Plombage Thoracoplasty Induced pneumothoraces
88
What is a Ghon Focus and Ranke's complex?
GF - Tuberculoma in primary TB. Ghon complex = Associated with hilar lymphadenopathy RC - Ghon complex develop calcification
89
Stages of TB
Latent Active - Primary - Re-activation
90
What is the theory behind old surgical techniques for managing TB?
To collapse the affected lobe and thereby reduce oxygenation to the TB microbes – however, TB can survive in low oxygen environments.
91
Difference between Mantoux and Quantiferon?
Mantoux - tubercullin injected intradermally. +ve with past reaction and vaccination. Negative in immunocompromised Quantiferon - interferon gamma response to TB antigen. Not present in BCG Less likely to have false negative in immunocompromised

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