Respiratory Flashcards
When do we use Light’s criteria?
When want to see if pleural effusion is a transudate or exudate.
Pleural protein between 25-35g/L
If < 30 = transudate
if > 30 = exudate
Outline Light’s Criteria
Pleural protein : serum protein ratio > 0.5
Pleural LDH : Serum LDH ratio > 0.6
Pleural LDH > 2/3 ULN of serum LDH
Need only one of these to fulfil criteria
Give some differentials for unilateral reduced chest expansion and reduced percussion note
Pleural effusion
Pneumonia
Atelectasis
Pulmonary oedema
Raised hemidiaphragm
Lobectomy
Pleural thickening e.g. pleural plaques
What clinical features may you expect on clinical examination of a patient with a pleural effusion?
Scars/biopsy/chest drain/ radiotherapy tattoos
Clubbing/cachexia
o2 requirement/ resp distress
Reduced expansion
Trachea deviated away from side of effusion
Stony dull percussion note
Decreased vocal resonance
Reduced air entry/breath sounds
Reduced vocal fremitus
Clinical signs that indicate malignancy as underlying cause
Clubbing
Cachexia
Tar staining
Scars
Radiotherapy tattoos
Lymphadenopathy
Small muscle wasting of hand
Horner’s
Yellow nail syndrome features
Yellow nails
Lymphoedema
Bronchiectasis
Pleural effusion
Causes of transudative pleural effusion
CCF
Cirrhosis
Nephrotic syndrome
Hypoalbuminaemia (CLD, nephrotic syndrome, malabsorption)
Meig’s
Myxoedema
Causes of exudative pleural effusion
Malignancy (primary bronchial/ pleural / malignant)
Infection: parapneumonic, TB effusion
PE
sarcoid
CTD: RA, SLE, Sclerosis
Yellow nail syndrome
Pancreatitis
What should you do if pH < 7.2 on pleural tap?
Insert a chest drain
What is a downfall of Light’s criteria?
High false negative rate
What can you use instead of Light’s criteria?
Serum albumin pleural gradient (serum albumin - pleural albumin), for exudate should be < 1.2g/dL
Investigations for pleural effusion
Obs
Urine dip - proteinuria
ABG
ECG
Sputum MCS
Bloods: FBC, UE, LFT (albumin), CRP, TFT, LDH, Coag, ANA/ESR/ANCA/complement if autoimmune
Imaging
- CXR
- USS
- CT with contrast
Pleural aspiration with USS guidance
Invasive: percutaneous pleural biopsy, bronchoscpy, thoracoscopy
When would you insert a chest drain for pleural effusion?
pH < 7.2
Turbid pleural fluid
Positive MC&S + gram stain
What do you send the pleural fluid for?
pH
Protein
LDH
Glucose (v low in RA)
Cytology
Gram stain, MCS
Microbiology / AFBW
When would you get a pleural amylase?
If suspecting pancreatitisWh
when would you get a pleural triglycerides?
If expecting chylothorax
What are some ddx for a white out on CXR?
Pleural effusion (away)
Pneumonectomy (towards)
Complete lung collapse (Towards)
Massive mass (Trachea away)
Mx options for recurrent pleural effusions?
Indwelling pleural catheter
Medical/surgical pleurodesis
What is Meig’s syndrome?
Right sided pleural effusion associated with ovarian fibroma
Exudative causes of pleural effusion
Malignancy
- Primary bronchial
- Mets
- Pleural (mesothelioma)
Infection
- Parapneumonic
- Emypema
- TB
Inflammatory
- RA
- Sarcoid
- SLE
PE
Significant negatives on clinical examination of a patient with pleural effusion
Fever
o2 requirement
Cancer features (clubbing, cachexia, radiotherapy scar)
Raised JVP and peripheral oedema (CCF)
Liver failure signs (leukonychia, spider naevi, gynaecomastia, clubbing)
CTD signs
What are general peripheral signs in pulmonary fibrosis?
Clubbing, cushingoid features, tachypnoea, central cyanosis.
What are signs of RA on peripheral inspection in PF?
Rheumatoid hands, nodules.
What are signs of systemic sclerosis in PF?
Sclerodactyly, calcinosis, microstomia, beak nose, telangiectasia.
What are chest findings in PF?
Thoracotomy scar +/- tracheal shift, fine end-inspiratory crackles.
What extra finding is associated with severe PF?
Cor pulmonale.
What are significant negatives in PF exam?
No cyanosis, no cor pulmonale, no signs of specific cause.
What are differentials for PF?
Bronchiectasis, pulmonary oedema
What are upper lobe causes of PF?
ABPA, pneumoconiosis, EAA, TB.
Ankylosing spondylitis
What are lower lobe causes of PF?
Sarcoidosis (mid zone), BANS ME drugs, asbestosis, IPF, rheumatologic diseases
What drugs cause PF? (BANS ME)
Bleomycin, Amiodarone, Nitrofurantoin, Sulfasalazine, Methotrexate.
What bedside investigations are useful in PF?
PEFR, ABG, ECG (RVH).
What blood tests are relevant in PF?
FBC, UE, LFT, ESR, CRP, ANA, RF, ACE, Ca2+, etc.
What imaging findings support PF?
CXR: reticulonodular shadowing, low lung volume; HRCT: fibrosis, honeycomb lung.
What spirometry findings indicate PF?
↓TLC, ↓RV, ↓FEV, ↓FVC, FEV1:FVC > 0.8, ↓transfer factor.
What is the MDT in PF management?
GP, pulmonologist, physio, psych, palliative care, nurses, dietitian
What supportive care is used in PF?
Stop smoking, pulmonary rehab, vaccinations, LTOT
What is the only cure for IPF?
Lung transplant.
What is the 5-year survival for IPF?
50%.
What are specific treatments for EAA, sarcoid, and CTD-related PF?
Steroids.
What are the typical symptoms of interstitial lung disease?
Dry cough, SOB (esp. on exertion), leg swelling.
What key history points should be taken in ILD assessment?
Occupation, hobbies, current/past drug use.
What are the key examination findings in ILD?
Clubbing, signs of steroid use, central cyanosis, fine end-inspiratory crackles.
What signs suggest pulmonary hypertension in ILD?
Raised JVP, left parasternal heave, loud P2
What connective tissue diseases are linked with pulmonary fibrosis?
RA, SLE, systemic sclerosis, polymyositis, dermatomyositis, Sjogren’s, MCTD, ankylosing spondylitis.
What are examples of pneumoconiosis?
Asbestosis, coal workers’, silicosis, beryliosis
What is extrinsic allergic alveolitis (EAA)? (Same as HP)
Alveolar inflammation from hypersensitivity to organic inhalants.
Name causes of EAA (HP).
Bird fancier’s lung, farmer’s lung, cheese washer’s lung, hot tub lung, malt worker’s lung, miller’s lung, wood worker’s lung.
What does spirometry show in ILD?
Restrictive pattern with decreased gas transfer.
What is the general approach to treatment of PF?
MDT, oxygen, treat infections, reduce exposure.
What medications are used in non-IPF fibrosis?
Steroids, azathioprine, cyclophosphamide.
Is there disease-modifying treatment for IPF?
No – only supportive and palliative care.
When is lung transplant considered in PF?
Rarely – in severe, progressive disease.
What should patients with occupational ILD be informed about?
Occupational health compensation.
ILD + pacemaker?/ discoloured slate grey skin
Amiodarone
Unilateral fine end inspiratory crackles and contralateral throacotomy scar with normal breath sounds
Single lung tx in patient with ILD
What happens to the TLC, TLCO and KCO in ILD?
All reduced
Broad mx options for ILD
Immunosuppression
Referral to NHSE Recognised ILD MDT if IPF for consideration of anti-fibrotics
Single lung transplant
DDx posterolateral thoracotomy scar
Pneumonectomy
Lobectomy
Open lung biopsy
Lung volume reduction surgery
Single lung transplant
Pleurectomy
Bullectomy
Indications for lobectomy and pneumonectomy
Lung cancer (NSCLC)
Infection: aspergilloma, TB, abscess
Solitary pulmonary nodule
Localised bronchiectasis
Uncontrollable haemoptysis in bronchiectasis
ILD
Lung volume reduction surgery in COPD
Lung transplant scars
Clamshell
Posterolateral thoracotomy (in single lung tx)
Most common indications for lung tx
Obstructive: COPD, a1at deficiency
Restrictive: ILD
Suppurative lung diseases: ie bronchiectasis, CF
Vascular: Pulmonary HTN
Apex in pneumonectomy
Shifted towards side of pneumonectomy
What could clubbing indicate in a patient with a lobectomy/pneumonectomy
Malignancy
ILD
Bronchiectasis
DDx reduced breath sounds and tracheal deviation
Pneumonectomy
Lung collapse
Pneumothorax
Pleural effusion (Expect trachea to be deviated away)
Clinical features if suspecting lung ca
Clubbing
Cachexia
Tar staining
Wasting of small muscles of hand
Horner’s
Radiotherapy tattoos
Lymphadenopathy
Pre-transplant lung function testing requirements
Lobectomy: FEV1 > 1.5L
Pneumonectomy FEV 1> 2L
VO2 Max > 15ml/kg/min
important negatives in surgical resp case
Clubbing
Cachexia
Radiotherapy scars
Tracheal deviation
Chest expansion, breath sounds
signs of underlying aetiology i.e. creps, crackles, prolonged expiratory wheeze, horner’s/small muscle wasting, pulm HTN
Criteria for lung surgery
FEV 1 > 1.5
VO2 max > 15ml/kg/min
no mets
good WHO performance status
no pulm HTN
Midline sternotomy in a resp station
Heart and lung transplant for pulm HTN, Eisenmenger’s (congenital heart disease) , CF
Complications of a lung transplant
Rejection: including bronchiolitis obliterans syndrome
Infection: CMV, HSV, PCP, aspergillus
Immunosuppression complications
VATS procedure indications
Lobectomy
Pleurodesis
Bullectomy
Decortication
Pleural biopsy
Lung biopsy
Lung volume reduction surgery
Reduced lung expansion in lung ca DDx
Pneumonectomy
Lobectomy
Large mass
Pleural effusion
Lobar collapse
Ix in suspected lung ca
Bedside:
History
Obs
Sputum MC&S
ABG
Lung function tests
Bloods
FBC, UE, LFT, Bone profile, coagulation
Imaging:
CXR
Staging CT CAP
Tissue diagnosis:
Pleural tap if effusion
Bronchoscopy
EBUS
Lung biopsy
Lymph node biopsy
Immunostaining for immunotherapy markers
Pre-op:
spirometry to assess fitness
Lung ca management:
Lung MDT: Radiologist, resp, resp CNS, cancer CNS, macmillan support groups, GP, psychologist
Medical: radiotherapy, chemotherapy, immunotherapy, LTOT
Surgical: wedge resection, lobectomy, pneumonectomy
Typical features of squamous cell ca
Central, cavitating lesion
Smokers
Squamous cell cancer paraneoplastic syndromes
Hyperthyroidism (ectopic TSH)
Hypercalcaemia (PTH secretion and bony mets)
Adenocarcinoma features
Peripheral, solid cancers
non-smokers
Adenocarcinoma paraneoplastic features
HPOA
Hypercalcaemia in lung ca
Bony mets or paraneoplastic from ectopic pTH secretion in squamous cell cancer
Small cell lung ca paraneoplastic features
LEMS
HPOA
Ectopic ACTH
SIADH
Lung cancer risk factors
Smoking
Asbestos exposure
Occupational exposure - beryllium
ILD
Radioactivity exposure ie uranium
