Respiratory Flashcards
What are the indications for VATS
o wedge resection or segmentectomy
o lobectomy
o decortication
o bullectomy
o treatment of recurrent pneumothoraces.
a VATS lobectomy you will see three scars on the left chest wall including a 10-cm transverse incision on the lateral chest.
What are the benefits of video-assisted thoracoscopic surgery over open thoracotomy?
A VATS procedure involves a smaller incision than an open thoracotomy.
* Reduced pain.
* Reduced wound complications.
* Reduced healing time.
* Reduced length of stay.
What are the possible indications for a lobectomy?
- lung cancer
- aspergilloma
- tuberculosis
4 lung abscess.
How would you investigate a patient that had a suspected lung cancer after taking a history, examination, and performing a chest X-ray?
- staging CT of the thorax, abdomen and pelvis
- a tissue diagnosis via bronchoscopy, a direct sampling, bronchoscopy and EBUS, and potentially CT-guided biopsy.
3 If there was a curative option - functional imaging with a PET/CT before working up the patient for surgery.
When performing a lobectomy, what FEV1 would you want the patient to have?
FEV1 of at least 1.5.
How would you work up a patient for surgery?
- A full history examination.
- Lung function tests, including transfer factor assessment.
- Cardiopulmonary exercise testing.
what is the VO2 max threshold which offers a better post- operative prognosis for the patient?
I would want the patient to have a VO2 max of at least 15 m/kg/min.
what are the different histological cell types of lung cancer.
Lung cancer can be broadly classified into two groups:
- small cell lung cancer, which accounts for approx. 20% of presentations, and Non-small cell lung cancer (NSCLC)
- NSCLC can be divided into: ▪
a. adenocarcinomas
b.squamous cell carcinoma
c.bronchoalveolar carcinoma
d. large cell carcinoma
e.neuroendocrine tumours.
How do treatment options differ for small cell and non-small cell lung cancer?
How would the clinical findings differ for a pneumonectomy vs a lobectomy?
Pneumonectomy.
1 Trachea deviated to the side of pneumonectomy
2. Breath sounds will be absent
3. Dull percussion
Lobectomy.
1. +/- The trachea may be deviated (towards the side of the lobectomy)
2. Breath sounds may be normal or may be reduced
3. The percussion note is likely to be normal. What are the respiratory causes of clubbing?
Management of symptomatic pneumothorax
- Needle Aspiration upto 2.5L via 2nd intercostal space (ICS), midclavicular line
- Insertion of chest drain if above fails
What investigations should you order in a suspected pneumothorax
- Inspiratory and expiratory CXR
- ABG
How would you investigate suspected asthma
Baseline observation - SpO2, Blood (infective excerbation), ABG
1. Blood eosinophils or FENO
2. Bronchodilator reversibility with spirometry
3. Peak expiratory flow variability
Other CXR, skin prick test for allergens or total IgE using blood tests through the radioallergosorbent test
How might a spirometry in an asthma patient differ than in a patient with chronic obstructive pulmonary disease?
An obstructive picture on the spirometry
1.a reduced FEV1; however, a preserved FVC 2. a reduced ratio between the two o although,
asthma is a revisable obstruction, I would expect there to be an improvement following the use of a bronchodilator.
o Usually 200 ml on a peak flow or an improvement by 15%.
Management of Asthma
- Low dose ICS/formoterol PRN (AIR)
- Low-dose MART
- Moderate-dose MART
What are some causes of air flow obstruction?
COPD
Asthma
Bronchiectasis.
obliterative bronchiolitis.
Asthma review
SIMPLE
Stop smoking
Inhaler technique
Monitoring
Pharmacotherapy
Lifestyle
Education
what are the other DDx of bibasal creps
- Heart Failure
- Bronchiectasis (coarse)
- Bilateral pneumonia
What investigations would you request for ILD
- bedside observations specifically pulse oximetry
- baseline bloods including a full blood count to determine signs of anaemia or infection
3 renal function tests
4 liver tests, to determine if any future medications will cause problems - cognitive tissue disorder o Test for autoimmune conditions, rheumatoid factor, double stranded DNA, ANA
- ABG, to determine his PO2 on room air
- baseline chest X-ray
- high resolution CT scan, investigating for honeycombing in keeping with fibrosis, or ground glass shadowing in keeping with uveitis
- an echo, investigating function of the right side of the heart and signs of pulmonary hypertension o spirometry.
What are the typical lung function characteristics associated with pulmonary fibrosis?
spirometry tests to demonstrate a restrictive pattern
1. reduction in the FEV1 and FVC
2. preserved ratio
3. reduced total lung capacity o reduced transfer factor.
How would you treat someone with interstitial lung disease?
- MDT approach including:
- physiotherapy with the use of occupational therapists
-respiratory nurses to address the patients shortness of breath and improve their quality of life.
- If the patient had an underlying connective tissue disorder, treat this using a disease modifying agent.
- If the patient had signs of ground glass shadowing on their CT scan they may respond well to steroids. * If the patient has idiopathic pulmonary fibrosis, I would treat them with an anti-fibrotic agent. (Pirfenidone )
causes of bronchiectasis
- Congenital: Kartagener’s and cystic fibrosis
- childhood infection: measles and TB
- Immune overactiivty: ABPA, IBD
- Immune under activity: hypogammaglobulinaemia. CVID
- Aspiration: chronic alcoholics, post stroke with swallowing and GORD
Tell me how you would investigate someone that you suspect to have bronchiectasis?
sputum culture and cytology
CXR: tramline and ring shadows
HRCT : signet ring
For specific cause
1. Immunoglobluins:m hypogammaglobulinaemia
2. Aspergillus serology
3. Genectic screening: CF
4. History of IBD : esp post total pancolectomy in UC
5. RA serology
Management of Bronchiectasis
PT - active cycle breathing postural drainage
Prompt antibiotics therapy for exacerbations
Long term treatment - low dose azithromycin
Bronchodilators/Inahled corticosteroids
surgery for localised disease
