Respiratory Flashcards
5 Respiratory causes of clubbing
- Lung carcinoma (but usually not small cell)
- Chronic suppurative lung disease such as bronchiectasis, lung abscess, empyema, CF
- IPF, asbestosis
- Mesothelioma
- Mediastinal diseases such as thymoma, lymphoma, carcinoma
Name 5 conditions in which clubbing DOES NOT occur
- COPD
- Sarcoidosis
- Extrinsic allergic alveolitis
- Coal worker’s pneumoconiosis
- Silicosis
Describe hypertrophic pulmonary osteoarthropathy and its causes
Characterized by presence of periosteal inflammation at the distal ends of long bones, wrists, ankles, metacarpal and metatarsal bones.
Clubbing and associated tenderness in the involved areas.
Causes:
- Primary lung carcinoma
- Mesothelioma
What is tracheal tug?
When the finger resting on the trachea feels it move inferiorly with each inspiration. This is a sign of gross overexpansion of the chest due to airflow obstruction.
3 causes of kyphoscoliosis
- Idiopathic (80%)
- Marfans syndrome
- Poliomyelitis
What is thoracoplasty and why was it performed?
Removal of large number of ribs on one side of the chest to achieve permanent collapse of the affected lung. Causes severe chest deformity. Used to be done for TB management but now no longer performed.
What indicates a diaphragmatic paralysis on clinical exam?
Paradoxical inward motion of the abdomen during inspiration when the patient is SUPINE.
Where is the upper level of the liver on percussion located at during clinical exam?
Usually at 5th rib in the right MCL.
If the chest is resonant below this level, it is a sign of hyperinflation.
Describe forced expiratory time
Time taken by a patient to exhale forcefully and completely through the open mouth after taking a maximum inspiration. Usually 3 seconds or less. Note any audible wheeze or cough.
Increased FET indicates airway obstruction.
Light’s criteria for pleural effusion
Exudate if:
Pleural/serum protein >0.5
Pleural LDH >2/3 ULN
Pleural/Serum LDH >0.6
4 causes of bronchial breath sounds
- Lobar pneumonia
- Localized fibrosis or collapse
- Above a pleural effusion
- Large lung cavity
Causes of bronchiectasis
Divided into congenital and acquired:
- Congenital:
CF
Primary ciliary dyskinesia
Congenital hypogammaglobulinaemia - Acquired:
- Infections in childhood (TB, pneumonia, measles, whooping cough)
- ABPA
- Localized obstruction - adenoma, foreign body
- RA, sjogrens syndrome
- Recurrent aspiration
Spirometry and suitability for pneumonectomy
If FEV1 >1.5L, this indicates that the patient could tolerate a pneumonectomy. A post operative FEV1 of 1 L or more is usually considered the minimum that will be tolerated.
Reversibility in spirometry
Increase in FEV1 OR FVC of 15% and at least 200 mL
Differential diagnosis to COPD
- Asthma - suggested by nocturnal symptoms, rapid response to treatment such as steroids, family history of allergy, eosinophilia in the sputum, reversibility of obstruction
- Bronchiectasis - daily sputum production recurrent chest infections, clubbing
Treatment of alpha 1 antitrypsin deficiency
Can consider replenishing the missing anti-protease which re-establishes antineutrophil elastase protection for the lower lung zones. Administered IV every week or monthly
Usually indicated only if A1AT levels <11 umol/L.
When would you consider operative management of COPD?
Consider lung transplant if severe COPD <65 age with no other significant comorbidities without previous thoracic surgery
LVRS are now less performed as lung function continues to deteriorate after resection (despite initial symptomatic benefit), and this operation was combined with an intensive rehabilitation and exercise program which may in itself account for the improvement.
Diagnosis of OSA
When is treatment for OSA shown to be effective?
Apnoeic spells >10 seconds and at least 5 events per hour must be recorded over several hours
Mild = 5 - 15
Moderate 16-30
Severe = >30
PaO2 monitoring over night can also be considered in patients with typical features of the condition - a positive test (several significant desaturation episodes/hr) is enough to justify treatment, however negative result does not rule out the diagnosis.
Treatment for OSA is effective in at least moderate OSA (AHI >15) - reduces symptoms, improves blood pressure and quality of life. In milder OSAs, it does improve daytime somnolence but less evidence of QoL or cognitive impairment improvement, and no evidence of impact on BP.
Causes of pulmonary infiltrates and eosinophilia
PLATE:
Prolonged pulmonary eosinophilia due to drugs (sulphonamides, sulfasalazine, penicillin, isoniazid)
Loeffler’s syndrome
ABPA
Tropical (microfilaria)
EGPA
Complications of cystic fibrosis
GI - difficulty maintaining weight, pancreatic insufficiency, constipation, bowel obstruction (due to defective water excretion into the bowel)
Heat exhaustion in hot weather - loss of large amount of salt in their sweat
Cardiac - cor pulmonale
Jaundice and variceal bleeding - focal biliary cirrhosis and PTHN can occur
Diabetes
Resp: major haemoptysis requiring bronchial artery embolization
Azoospermia in male leading to infertility
Diagnosis of CF
Sweat chloride >70 mmol/L suggests CF in adult
Management of CF
- Intensive and repetitive physiotherapy, use of flutter valve, postural drainage
- Influenza/pneumococcal vaccine
- Assessment and management of malabsorption - pancreatic enzyme supplements, vitamin supplements, frequent small meals
- dornase alfa nebulizers (Human recombinant DNAse) to help degrade the concentration of DNA in the sputum reducing sputum viscosity and allow better clearance of pulmonary secretion.
Indications for lung transplantations in COPD, CF/bronchiectasis, ILD, pulmonary hypertension
Age criteria for lung transplant:
COPD - FEV1 <25% predicted, PaCO2 >55 mmHg
CF/Bronchiectasis - FEV1 <30% or complications such as cachexia, severe haemoptysis, or PacO2 >50mmHg, PaO2 <55mmHg
ILD - progressive symptoms, DLCO <60%
Pulmonary hypertension - NYHA class III or IV symptoms, pulmonary artery pressure >55 mmHg
Age criteria:
Unilateral <65
Bilateral <60
Heart and lung <55
Complications post lung transplant
- Rejection - early rejections are common and treated with prednisone. Symptoms of early rejection include malaise, fever, dyspnoea and cough. Transbronchial biopsy is performed if there are any suspicion of rejection and to allow accurate diagnosis.
- Infection - most common cause of death due to combination of immunosuppression, impaired ciliary activity. Commonly CMV, adenovirus, influenza A. Patients now receive routine 3 months prophylactic antibiotics, antiviral and antifungal treatment.
- Immunosuppressant side effects- metabolic complications, osteoporosis, peripheral neuropathy.
- Bronchiolitis obliterans - more common with burden of acute rejection episodes and HLA mismatch. Gradual onset dyspnoea, fatigue and cough.
- Disease recurrence - sarcoidosis, idiopathic ILD.
UIP vs NSIP pattern
UIP pattern
- Subpleural and basal predominance
- Reticular abnormality
- Honeycombing and traction bronchiectasis
NSIP pattern
- Immediate subpleural sparing
- Ground glass opacities
- Traction bronchiectasis
