Respiratory Flashcards
Types of lung cancer
Small cell vs NSCLC
NSCLC:
- Squamous most common
- Adeno - classically nonsmoker
- Large
Small cell often metastatic at presentation, almost all smoking
Small cell lung cancer management
- Few surgical options given usually presents with advanced disease
- Therefore chemo+/-immunotherapy
- Some evidence for prophylactic cranial irradiation
- Small cell often produces polypeptide hormones e.g. ACTH
Lung cancer pathology options
- Sputum cytology (very low sens, better w central lesions)
- VATS
- Bronchoscopy + direct or EBUS. EBUS better for staging as lesion + nodes can be accessed
- Transthoracic needle asp.
Lung cancer central vs peripheral lesions
Central - squamous, small, large
Peripheral - Adeno
eGFR mutation in lung cancer relevance
- Site for targeted TK targeted therapy
- More likely positive in low/no smoking pts
ECOG performance status
Eastern Coop Onc group
0 - Fully active
5 - deceased
VATS indications
Wedge resection (good for benign lesions e.g. aspergillus)
Bullectomy
Lung biopsy
Recurrent PTx
Lobectomy
VATS vs thoracotomy scars
Thoracotomy:
- Large (15-20cm) lateral chest wall scar
- Possibly drain scar also
VATS
- 3 scars that triangulate
- 3-6cm scar on lateral wall largest
Benefits of VATS over thoracotomy
Smaller incision -> reduced healing time, bleeding
Lobectomy indications
Lung cancer
Aspergilloma
TB
Lobectomy/pneumonectomy workup
PFTs inc transfer factor and exercise testing.
FEV1 >1.5L for lobectomy, >2L for pneumonectomy
VO2 max >15ml/kg/min
Respiratory causes of clubbing
- Lung cancer
- Chronic suppurative conditions - bronchiectasis, abscess, CF
- Interstitial lung disease
Signs to distinguish lobectomy from pneumonectomy
Pneumonectomy:
- trachea deviated
- unilateral reduced expansion
- dull hemothorax
- absent tactile fremitus beneath the scar
- Bronchial breathing in upper zones may be present
Lobectomy:
- Trachea central if old
- Lower - dull lower zone with abs breath sounds
- Upper - Hyper-resonant upper zone
Single lung transplant indications
“Dry lung”
- COPD
- Fibrosis
COPD biggest indication for transplant worldwide
Double lung transplant indications
“Wet lung”
- CF
- Bronchiectasis
- Pulmonary hypertension
(or ILD/COPD - prognosis better for double lung for all indications)
COPD biggest indication for transplant worldwide
VATS indications resp
- Lung resection (wedge/lobe/segment)
- Bullectomy
- Pleural drainage/pleurodesis
- Diagnostic
PTx management
Asymptomatic - nothing
High risk features - chest drain if >2cm
Symptomatic, no HRF, sufficient size - aspirate, drain or conservative
Persistent >24-48h? Recurrent? Consider pleurodesis/pleurectomy
PTx high risk features
- Sig desat
- HD instab
- Bilat
- Underlying lung disease
- Haemoptx
Asthma chronic management
1- AIR therapy - anti-inflammatory reliever (formoterol/ICS) PRN
2 - MART - same inhaler regular
3 - MART higher dose
4 - Ref to specialist or LTRA (montelukast) or LAMA (e.g. tiotropium)
Role of FeNO in asthma diagnosis
- FeNO = Fraction exhaled nitric oxide
- NO in parts per billion
- Raised NO demonstrates airway inflammation as inflammatory cytokines induce NO synthase. NO has a role in negative feedback of bronchoconstriction
- > 50ppb supportive of asthma dx
Asthma investigation
(Progress if each step normal)
1 - Eosinophils or FeNO
2 - Spirometry (FEV1:FVC<0.7) with reversibility
3 - PEFR diary with variability (>20%)
4 - Bronchial challenge
BTS asthma spirometry results
- Reversibility PEFR 12% and FEV1 200ml more than baseline
Basal pulmonary fibrosis causes
- ILD
- Asbestosis
- Connective tissue diseases (RA, scleroderma, systemic sclerosis, IBD)
- Drugs - bleomycin, nitrofurantoin, amiodarone. (MTX now considered unlikely to cause fibrosis)
- Chronic aspiration
Apical pulmonary fibrosis causes
- TB
- Hypersensitivity pneumonitis aka extrinsic allergic alveolitis (e.g. birds) / ABPA late stage
- Coal miners pneumoconiosis -> progresses to progressive massive fibrosis
- Silicosis -> progressive massive fibrosis
- Ank spond
- Sarcoidosis
Pulmonary fibrosis causative drugs
- Nitrofurantoin
- Bleomycin
- Amiodarone
- Sulfasalazine
Fibrosis PFTs
- Reduced FEV1, Reduced FVC, preserved FEV1/FVC (>0.8)
- Reduced transfer factor (TLCO, KCO)
IPF management
- Nintedanib / pirfenidone if PVC <80% - antifibrotics
- Lifestyle - stop smoking
- Consider referral for transplant
- ACP - median survival 2-5 years
+ Supportive:
- Symptom management
- Oxygen
- Treat exacerbations
- PT/OT/resp CNS
IPF investigations
Bedside:
- PFTs
- ABG (T1RF, T2 in end stage)
- Obs
Bloods:
- CRP, ESR
- ANA & RF positive in some
- anti-CCP and myositis panel suggestive of alternative to IPF
Imaging:
- CXR
- HRCT most important
Special:
- Consider BAL/biopsy if unclear diagnosis
What is NSIP
Non specific interstitial pneumonia
- Idiopathic interstitial lung disease
- Predominant ground glass > honeycombing on CT
- Therefore more responsive to antiinflammatories - steroids, then DMARDs e.g. MMF
What is cryptogenic organising pneumonia
ILD affecting peripheral alveoli/bronchioles
Often caused by drugs, infection, RA
Pred usually used to treat
Causes of EAA/HP
Microorganisms:
- Actinomycetes (bacteria)- farmer’s lung
- Aspergillus (this is not ABPA)
Animal proteins:
- Bird fancier’s lung
- Large farm animals
Occupational:
- Metalworking fluid
- Epoxy resins
- Spray paints
Presents with fevers/chills as well as resp symptoms.
Not IgE so not wheezy
ILD lung transplant indications
Refer for consideration when:
UIP/IPF & fibrotic forms of NSIP should be referred regardless of lung function (i.e. at diagnosis) if fit enough.
Others referred when FVC<80% or O2 req
Cystic fibrosis genetics
CFTR gene (cystic fibrosis transmembrane conductance regulator). Autosomal recessive.
Most common = delta F508 gene
Cystic fibrosis important bacteria
- Pseudomonas most common in adults
- (S aureus in childhood)
- Burkholderia & mycobacterium abscessus contraindication to transplant, and poor prognostic indicator
Extrapulmonary cystic fibrosis
- Pancreatic insufficiency -> poor absorption fat soluble vitamins, diabetes
- Chronic liver disease
- Hypersplenism
- Osteoporosis and fractures
- Gall stones
- Kidney stones
- Subfertility. Absence vas deferens in males
- Constipation and distal intestinal obstruction syndrome
CF most common presentation
- Screening on heel prick in infancy
- Followed by genetic testing & sweat test
CF medical therapies
Respiratory:
- Nebulised Abx
- Prophylactic Abx
- Nebulised hypertonic saline and mucolytics (DNase)
- CFTR modulators - e.g. ivacaftor, often in combination e.g. Trikafta
Leading cause of death post lung transplant
Bronchiolitis obliterans - chronic rejection. Usually terminal event.
20% 1 year mortality.
Lung transplant immunosuppression
- Tacrolimus
- MMF
- Steroids
in combination
Lung transplant contraindications
Loads!
- Recent malignancy <5y
- Poor PS / comorbidities
- Certain infections e.g. Burkholderia and Mycobacterium abscessus
- Smoking
- BMI >35 or <17
- Poor treatment adherence
Transudate vs exudate effusion
Protein <25g/L = transudate, >35g/L = exudate
Between - lights criteria:
- Pleural/serum protein >0.5
- Pleural/serum LDH >0.6
- Pleural LDH >2/3 ULN serum LDH
Any one = exudative
Empyema effusion findings
- pH <7.2
- Frank pus
