Respiratory Flashcards
1
Q
Pleural Effusion
Examination
(periph inspection, chest, significant negatives)
A
Peripheral Inspection
- Paraphernalia
- Chest drain
- Evidence of Specific Cause
- Cancer: clubbing, cachexia, LNs
- Pneumonia: febrile
- CCF: ↑JVP, S3, ascites, ankle oedema
- CLD: clubbing, leukonychia, spiders, gynaecomastia
- CTD: rheumatoid hands, malar rash
Chest
- Tracheal shift: away from lesion
- ↓ expansion unilaterally
- PN: stony dull
- Auscultation
- ↓ AE
- ↓ VR
Significant Negatives Absence of
- Fever
- Clubbing
- raised JVP and peripheral oedema
- Features of CTD
2
Q
Differential of Dull Lung Base
A
- Consolidation: bronchial breathing + crackles
- Collapse: ↑ VR
- Pleural effusion
3
Q
Causes of Pleural effusion
A
Light’s Criteria for Dx of an Exudative Effusion
- Effusion : serum protein ratio >0.5
- Effusion : serum LDH ratio >0.6
- Effusion LDH is 0.6 x ULN
4
Q
Pleural effusion Hx
A
Symptoms: SOB, pleurisy
Cause:
- Fever, sputum
- Smoking, wt. loss, haemoptysis
- Previous MI, orthopnoea, PND
- Hepatitis
5
Q
Investigation of pleural effusion
A
- *Sputum**: MC+S, cytology
- *Imaging**
- CXR
-
Dependent homogenous opacification c¯ meniscus
- Unilateral or bilateral
- Cardiomegaly
- Coin lesions
- Hilar LNs
- Apical TB
-
Dependent homogenous opacification c¯ meniscus
- US: may guide pleurocentesis
- Volumetric CT
Blood
- FBC: ↓Hb
- U+E: ↑ Cr
- LFTs: ↓ albumin
- TFT: ↑TSH
- ESR: ↑ in CTD
- Ca: ↑ in Ca
Diagnostic Pleurocentesis
Percuss upper boarder and go 1-2 spaces below. Infiltrate down to pleura c¯ lignocaine + aspirate c¯ 21G needle
Send for:
- Chemistry: protein, LDH, pH, glucose, amylase
- Bacteriology: MCS, auramine stain, TB culture
- Cytology
- Immunology: RF, ANA, complement
Light’s Criteria for Dx of an Exudative Effusion
-Effusion : serum protein ratio >0.5
-Effusion : serum LDH ratio >0.6
-Effusion LDH is 0.6 x ULN
Empyema: turbid fluid, ↓ glucose and pH <7.2
Pleural Biopsy
- If pleural fluid is inconclusive
- CT-guided c¯ Abrams needle
6
Q
Management of Pleural effusion
A
- Rx underlying cause
- May use drainage if symptomatic (≤2L/24h)-Repeated aspiration or Intercostal drain
- Pleurodesis c¯ talc if recurrent malignant effusion
- Persistent effusions may require surgery or portable chest drainage system
7
Q
Bronchiectasis
Examination
(peripheral inspection, chest, extras, completion)
sig negatives and differentials
A
Peripheral Inspection
- General
- Clubbing
- Sputum pot
- Small and young: CF
- Cachexia
- LNs
- Tachypnoea
- Evidence of Specific Cause
- RA: rheumatoid hands
- Yellow nails
- CF: young pt., nasal polyps
- Hypogammaglobulinaemia: splenomegaly
- IBD: abdominal scars
Chest
- ± thoracotomy scar
- Portacath or Hickman line / scars: CF
- Coarse, wet crackles
- May change with cough
- Localised / patchy: 2O to infection
- Widespread: 2O to systemic disease
- ± monophonic wheeze
- Dextrocardia
Extras
- Cor pulmonale
Completion
- Examine the nose for polyps
- Associations
- asthma* (particularly late-onset asthma)
- aspirin sensitivity*
- allergic/non allergic rhinitis
- cystic fibrosis
- Associations
- Examine the abdomen for scars and splenomegaly
Significant Negatives
- Cor pulmonale
- Specific cause: e.g. RA hands
Differential
- Idiopathic pulmonary fibrosis
- Chronic lung abscess
8
Q
Causes of bronchiectasis
congenital/acquired
A
Congenital
- CF
- PCD / Kartagener’s
- Young’s: azoospermia + bronchiectasis
- Hypogammaglobulinaemia: XLA, CVID, SAD
Acquired
- Idiopathic
- Post-infectious: pertussis, TB, measles
- Obstruction: tumour, foreign body
- Associated: RA, IBD (esp. UC), ABPA
9
Q
Bronchiectasis
Hx
A
Hx
- HPC: dyspnoea, cough, sputum, haemoptysis, wt. loss
- Cause: recurrent infections, arthritis, diarrhoea
- Smoking status
10
Q
Bronchiectasis investigations
A
Bedside
- PEFR
- Dipstick: proteinuria – amyloidosis
- *Sputum**: MC+S, cytology
- *Blood**
- FBC: ACD
- Serum Ig: may do provocative testing
- Aspergillus: RAST, precipitins, ↑IgE, eosinophilia
- RA: anti-CCP, RF, ANA
Imaging
- CXR: tramlines and ring shadows (bunch of grapes)
- HRCT
- Signet ring sign: thickened dilated bronchi + smaller adjacent vascular bundle
- Pools of mucus in saccular dilatations
- *Spirometry** Obstructive
- *Other**
- Bronchoscopy + mucosal biopsy
- Focal obstruction
- PCD
- CF sweat test
- Aspergillus skin prick testing
11
Q
Bronchiectasis
Complications
A
- Cachexia
- Pulmonary HTN
- Massive haemoptysis
- Type 2 respiratory failure
- Amyloidosis
12
Q
Management of Bronchiectasis
A
Conservative
- MDT: GP, pulmonologist, physio, dietician, immunologist
- Physio: postural drainage, active cycle breathing, rehab
Medical
- Abx
- Exacerbations: e.g. cipro for 7-10d
- May use prophylactic azithromycin
- Bronchodilators: nebulised β agonists
- Treat underlying cause
- CF: DNAase, pancreatin (Creon), ADEK vitamins
- ABPA: Steroids
- Immune deficiency: IVIg
- Vaccination: flu, pneumococcus
Surgical
- May be indicated in severe localised disease or obstruction
13
Q
Cystic Fibrosis
Genetics, pathophysiology
A
Genetics
- Incidence: 1/2500 live Caucasian births
- Carrier frequency: 1/25
- Autosomal recessive
- Mutation in CFTR gene on Chr 7
- Commonly ΔF508
Pathophysiology
- → ↓ luminal Cl secretion and ↑ Na reabsorption → viscous secretions.
- Bronchioles → bronchiectasis
- Pancreatic ducts → DM, malabsorption
- GIT → Distal Intestinal Obstruction Syndrome
- Liver → gallstones, cirrhosis
- Fallopian tubes → ↓ female fertility
- Seminal vesicles → male infertility
14
Q
CF Sx and Ix
A
Dx
- Genetic screening for common mutations
- Immunoreactive trypsinogen (neonatal screening)
- Sweat test: Na and Cl > 60mM
- False +ve: hypothyroidism, Addison’s
- Faecal elastase: tests pancreatic exocrine function
Ix
- Bloods: FBC, LFTs, clotting, ADEK levels, glucose tolerance test
- Sputum MC+S
- CXR: diffuse tramlines and rings
- Abdo US: fatty liver, cirrhosis, pancreatitis
- Spirometry: obstructive defect
- Aspergillus serology / skin test (20% develop ABPA)
15
Q
CF management
A
- *MDT**: GP, gastro and resp physicians, physio, dietician, specialist nurse
- *Chest**
- Physio: postural drainage, active cycle breathing
- Abx: acute infections and prophylaxis
- Mucloytics: DNAse
- Segregate from other CF pts.: risk of transmission
- Pseudomonas
- Burkholderia
- Vaccination: flu, pneumococcus
- Advanced: heart-lung transplant
GI
- Pancreatic enzyme replacement: pancreatin (Creon)
- ADEK supplements
- Insulin
Other
- Rx of complications: e.g. DM
- Fertility and genetic counselling
- DEXA osteoporosis screen
16
Q
CF prognosis
A
Prognosis
- Mean survival 35yrs but rising
- Poorer prognosis if infected c¯ Burkholderia cepacia
17
Q
PCD and Kartagener’s
A
PCD and Kartagener’s
- Autosomal recessive defect in ciliary motility
- Poor mucociliary clearance → chronic recurrent inflammation and bronchiectasis.
- ↓ sperm motility in males → infertility
Kartagener’s Syndrome: Situs inversus + PCD (~50% of individuals c¯ PCD)
- Situs inversus
- Chronic sinusitis
- Bonchiectasis
18
Q
Young’s Syndrome
A
- Bronchiectasis
- Rhinosinusitis
- Azoospermia (no sperm in semen) → ↓ fertility
19
Q
Hypogammaglobulinaemia
(what/presentation/causes)
A
- Primary immune deficiency due to ↓ Ig*
- *Presentation**
- Recurrent sinopulmonary infections → bronchiectasis
- Diarrhoea
- Commonly encapsulates: pneumococcus, haemophilus
Causes
X-linked Agammablobulinaemia: Bruton’s
- X-linked recessive mutation of Bruton’s tyrosine kinase
- Failure to generate mature B cells → ↓ Ig
- Rx: pooled Ig → passive immunity
Common Variable Immunodeficiency
- Commonest 1O immune deficiency: 1/5000
- Splenomegaly: 25-50%
- Normal IgM, ↓IgG, ↓IgA
Specific Antibody Deficiency: SAD: Normal Ig levels but inability to make specific antibodies
20
Q
Yellow Nail Syndrome
A
- Very rare
- Yellow dystrophic nails
- Pleural effusions
- Lymphoedema: lymphatic hypoplasia
- Bronchiectasis
21
Q
Allergic Bronchopulmonary Aspergillosis
(what/presentation/Ix/Rx)
A
T1 and T3 HS reaction to Aspergillus fumigatus
Bronchoconstriction → bronchiectasis
Presentation
- Dyspnoea, wheeze
- Productive cough
- Bronchiectasis
Ix
- ↑IgE and eosinophilia
- +ve skin prick test or RAST
Rx
- Prednisolone + bronchodilators
22
Q
Pulmonary fibrosis
peripheral inspection (gen/spec causes), chest, sig negatives
A
Peripheral inspection
- General:
- Clubbing
- cushingoid
- No sputum
- Tachypnoea, central cyanosis
- Evidence of specific cause:
- RA: rheumatoid hands, nodules
- SS:
- Slerodactyly, calcinosis, microstomia, beak nose, telangiectasia
- SLE: malar rash
- Ankylosing Spondylitis: kyphosis
- Sarcoidosis: EN
- Radiation: tattoos on chest
Chest:
- Thoracotomy scar: single lung Tx
- tracheal shift towards fibrosis: upper lobe
- Find end inspiratory crackles (no change on coughng)
- ?cor pumonale
sig negatives:
- cyanosis
- cor pulmoale
- specific cause e.g. RA hands or sclerodactyly
23
Q
Pulmonary fibrosis
differential diagnosis
A
Bronchiectasis
chronic lung abscess
24
Q
Pulmonary fibrosis
causes
Upper
lower (drugs; BANS ME)
A
Upper:
- Asperillosis: ABPA
- Pneumoconicosis: coal, silica
- Extrinsic allergic alveolitis
- NEgative, sero-arthtropathy
- TB
Lower:
- Sarcoidosis (mid)
- Toxins: BANS ME:
- Bleomycin, busulfan
- amiodarone
- nitrofurantoin
- sulfasalaine
- methotrexate
- Asbestos
- IPF
- Rheum: Ra, SLE, Scleroderma, Sjogrens, PM/DM
25
Pulmonary fibrosis:
history Qs
* HPC: dyspnoea, cough, sputum, wt loss
* cause: arthritis, radiation, occupation, hobbies, DHx
* Smoking status
26
Pulmonary fibrosis
Investigations
(bedside, bloods, imaging, special)
Bloods
* FBC: anaemia exacerbates dyspnoea
* ABG: low PaO2, high PCO2
* IPF: high ESR, high CRP, ANA (30%), RF (10%), raised Ig
* EAA: +ve serum precipitins
* CTD: C3/4, CCP (RF, ANA), ScL-70, centromere
* Sarcoid: serum ACE, Ca2+
Imaging:
* CxR: reticulonodular shadowing, reduced lung volume
* HRCT: fibrosis, honeycomb lung
Spirometry: restrictive
* low TLC, low RV, low FEV, low FVC
* FEV: FVC \>0.8
* reduced transfer factor
Echo: PHT
BAL: disease activity: high lymphocyts\>PMNs=better prognosis
Lung biopsy: usual intersitial pneumonia patterns
27
Pulmonry fibrosis Management
MDT/Rx cause/supportive/surgery
?prognosis: 5 yrs survival
**MDT:** GP, pulmonologist, physio, psych, palliative, specialist nurse, pt fam
**Rx cause:**
* EAA: steroids
* Sarcoidosis: steroids
* CTD: steroids
**Supportive:**
* Stop smoking
* pulmonary rehabilitation
* LTOT
* Symptomatic Rx:
* anti-tussives e.g. codein phosphate
* HF: diuretics, BB, ACEi
**Surgery:** lung Tx offers only cure for IPF
**Prognosis:** IPF: 50% 5 yr surival
28
What is systemic sclerosis:
* Systemic sclerosis is a condition of unknown aetiology characterised by hardened, sclerotic skin and other connective tissues.*
* It is four times more common in females*
29
What are the three patterns of systemic sclerosis
**Limited cutaneous systemic sclerosis**
* Raynaud's (may be first sign)
* scleroderma affects: _face and distal limbs_
* anti-centromere antibodies
* a subtype of limited systemic sclerosis is **CREST** syndrome:
* Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
**Diffuse cutaneous systemic sclerosis:**
* scleroderma _affects trunk and proximal limbs_
* scl-70 antibodies
* hypertension, lung fibrosis and renal involvement seen
* poor prognosis
**Scleroderma** (without internal organ involvement)
* tightening and fibrosis of skin
* may be manifest as plaques (morphoea) or linear
30
COPD
Examination:
Peripheral: periphernalia/gen/spec
Chest
Extra
Sign negatives
**Peripheral Inspection**
* Paraphernalia
* Inhalers
* Peak flow meter
* Nebuliser
* General
* Airflow obstruction
* Pursed lip breathing
* Splinting diaphragm
* Cushingoid
* Cyanosed
* Cachetic
* Specific
* Hands
* Tar staining
* CO2 retention flap
* Bounding pulse
* Face
* Plethora: ↑Hb
* Central cyanosis
**Chest**
* Barrel-shaped
* ↓ cricosternal distance
* ↓ expansion bilaterally
* PN: resonant
* Auscultation
* ↓ breath sounds
* Expiratory wheeze
* Prolonged expiratory phase
* Evidence of Hyperexpansion
* ↓ cricosternal distance
* Loss of cardiac dullness
* Palpable liver edge
**Extra:**Cor Pulmonale
* ↑ JVP
* Left parasternal heave: RV hypertrophy
* Loud P2 ± S3
* MDM of tricuspid regurg
* Ascites and pulsatile hepatomegaly
* Peripheral oedema
**Significant Negatives**
* CO2 retention
* Cor pulmonale
* Clubbing: could indicate Ca
31
Differential for COPD patient (2)
1. Chronic asthma
2. Bronchiectasis
32
Key history Qs in COPD
| (5)
1. **Symptoms**: cough, sputum, dyspnoea
2. **Limitation**: exercise tolerance
3. **Cause**: smoking Hx, FHx
4. **Control**: exacerbations, admissions
5. **Therapy**: inhalers, vaccinations, home O2
33
Definitions of COPD (2)
**Chronic bronchitis:** Cough productive of sputum on most days for ≥3mo on ≥2
consecutive years
**Emphysema:** Histological description of alveolar wall destruction c¯ airway collapse and air trapping
34
Key investigations in COPD
Bedside/spirometry/blood/Imaging/other?
**Bedside**
* PEFR
* BMI: independent mortality RF in COPD
* Sputum: MC+S
**Spirometry**: obstructive
* ↑ TLC and residual volume (RV)
* FEV1 \<80%
* FEV1:FVC \<0.7
* ↓ *transfer factor*
**Bloods**
* FBC: polycythaemia, ↑ WCC in exacerbations
* ABG: Type 2 resp failure
* CRP: if infective exacerbation
* Albumin: malnutrition
* α1-AT levels: if young and FHx
**Imaging**
* CXR
* Acute
* Consolidation
* Pneumothorax
* Chronic
* Hyperinflation: \>10 posterior ribs, flat diaphragm
* PHT: prominent pulmonary As, peripheral oligaemia
* Bullae
* Echo
* Cor pulmonale
**Other**
* 6 minute walk
* ECG: RVH
35
COPD classification
GOLD Classification: Global Initiative for Obstructive Lung Disease
*Multidimensional classification to tailor therapy to pt.*
**Parameters**
1. mMRC dyspnoea score
2. Airflow limitation
3. No. of exacerbations per year
* *mMRC Dyspnoea Score**
1. SOB only on ***vigorous*** exertion
2. SOB on ***hurrying or walking up stairs***
3. ***Walks*** slowly or has to stop for breath
4. Stops for breath after ***\<100m / few min***
5. Too breathless to l***eave house*** or SOB on ***dressing***
* *Airflow Limitation**
1. Mild: FEV1 ***\>80%*** (but FEV/FVC \<0.7 and symptomatic)
2. Mod: FEV1 ***50-79%***
3. Severe: FEV1 ***30-49%***
4. Very Severe: FEV1 ***\<30%***
36
COPD Management
General (4)
Medical
Surgical
**General**
* *MDT*
* GP, dietician, physio, resp physician, specialist nurses
* Regular review 1-2x / yr
* *Smoking Cessation*: single most important intervention
* Specialist nurse and support programme
* Nicotine replacement therapy
* Varenicline: partial nicotinic agonist
* *Pulmonary Rehabilitation Therapy*
* Tailored exercise programme
* Disease education
* Psychosocial support
* *Co-morbidities*
* Nutritional assessment and dietary support
* CV risk Mx
* Vaccination: pneumococcal and seasonal influenza
**Medical Mx**
* Principal Therapies
* Anti-muscarinics: short- or long-acting
* β-agonists: short- or long-acting
* Inhaled corticosteroids: in combination c¯ β-B
* Other Therapies
* Theophylline or Roflumilast: PDIs
* Carbocisteine: mucolytic
* Home emergency pack for acute exacerbations
* LTOT
* Aim: PaO2 ≥8 for ≥15h / day (↑ survival by 50%)
* Indications
* Sable non-smokers c¯ PaO2 \<7.3
* PaO2 \<8 + cor pulmonale or polycythaemia
**Surgical Mx**
* Recurrent pneumathoraces or large bullae
* Bullectomy or lung reduction surgery
37
Management of COPD acute exacerbation
(and Ix: 4)
Ix
1. **PEFR**
2. **Bloods**: FBC, U+E, ABG, CRP, cultures
3. Sputum **culture**
4. **CXR**: infection, pneumothorax
38
Mortality
for in hospital COPD
15% in-hospital mortality
39
What to do on discharge following acute COPD exacerbation (6)
Discharge
1. Spirometry
2. Establish optimal maintenance therapy
3. GP and specialist f/up
4. Prevention using home oral steroids and Abx
5. Pneumococcal and Flu vaccine
6. Home assessment
40
Tool to predict mortality in COPD
**BODE Index (4)**
*Multidimensional tool to predict mortality in COPD
Uses multiple independent risk factors*
1. BMI
2. Obstruction: FEV1
3. Dyspnoea: MRC score
4. Exercise capacity: 6 min walk
41
Asthma
Examination
peripheral inspection: paraphenalia/general/specific
Chest
Sign negatives
**Peripheral Inspection**
* Paraphernalia
* Inhalers
* Peak flow meter
* Nebuliser
* General
* Cushingoid
* Specific
* Oral thrush
**Chest**
* Harrison sulcus
* Auscultation
* Usually normal
* May be ↓ AE and mild wheeze
**Significant Negatives**
* CO2 retention
* Cor pulmonale
* Clubbing: could indicate Ca
42
Key history Qs in asthma Pt (6)
1. Symptoms: cough, dyspnoea, wheeze, diurnal variation
2. Limitations: exercise, sleep, work
3. Cause: atopy, exercise, cold, smoking
4. Control: SABA use, attacks, admissions, ITU
* Check peak flow diary
5. Therapy: oral steroid use, check inhaler technique
6. Assocs.
* GORD: dyspepsia
* Churg-Strauss: recent onset, rash, neuropathy
43
Definition of asthma
*Episodic, reversible airway obstruction due to bronchial
hyper-reactivity to a variety of stimuli.*
44
Investigation of asthma pt
bedsire/bloods/cxr/special (3)
* *Bedside**: PEFR
* *Bloods**
* FBC (eosinophila)
* ↑IgE
* Aspergillus serology
* *CXR**: hyperinflation
* *Spirometry**: obstructive
* ↓ FEV1, ↑RV
* FEV1:FVC \< 0.75
* ***≥15% improvement in FEV1 c¯ β-agonist***
**PEFR** monitoring / diary
* Diurnal variation \>20%
* Morning dipping
**Atopy**: skin-prick testing, RAST
45
Management of Asthma
General + guidelines
**General**
* MDT: GP, specialist nurses, respiratory physician
* Technique for inhaler use
* Avoidance: allergens, smoke (ing), dust
* Monitor: Peak flow diary (2-4x/d)
* Educate
* Liaise c¯ specialist nurse
* Need for Rx compliance
* Emergency action plan
46
Features of well controlled asthma (5)
1. No exacerbations
2. No reliever therapy: no PRN salbutamol
3. No night time waking
4. \<20% diurnal variation
5. Normal lung function
47
Key Hx Qs in acute severe asthma (4)
* Precipitant: infection, travel, exercise?
* Usual and recent Rx?
* Previous attacks and severity: ICU?
* Best PEFR?
AMPLE
48
Key Investigations in acute severe asthma
* PEFR
* ABG
* PaO2 usually normal or slightly ↓
* PaCO2 ↓
* If PaCO2 ↑: send to ITU for ventilation
* BloodS: FBC, U+E, CRP, blood cultures
49
Features of severe asthma (4)
1. PEFR \<50%
2. Can’t complete sentence in one breath
3. RR \>25
4. HR \>110
50
Features of life threatening asthma (7)
1. PEFR \<33%
2. SpO2 \<92%, PCO2 \>4.6kPa, PaO2 \<8kPa
3. **C**yanosis
4. **H**ypotension
5. **E**xhaustion, confusion
6. **S**ilent chest, poor respiratory effort
7. **T**achy-/brady-/arrhythmias
51
Differential of Acute severe asthma
Presents as: *'acute breathlessness and wheeze'*
* pneumothorax
* acute exacerbation of COPD
* Pulmonary oedema
52
Asmission criteria for acute severe athma
* Life-threatening attack
* Feature of severe attack persisting despite initial Rx
* May discharge if PEFR \> 75% 1h after initial Rx
53
Acute severe asthma
When to discharge?
What to do on discharge? (4)
**_When do dischage_**
* Been stable on discharge meds for **24h**
* **PEFR \>75%** c¯ **diurnal** variability **\<20%**
**_Discharge Plan_**
* TAME pt.
* Technique for inhaler use
* Avoidance: allergies, snoke, dust
* Monitor: peak flow diary (2-4x/day)
* Educate:
* liase with specialist nurse
* need for Rx compliance
* emergency action pack
* PO steroids for 5d
* GP appointment w/i 1 wk.
* Resp clinic appointment w/i 1mo
54
Management of acute severe asthma
55
Lung Cancer
Peripheral inspection: general, hands, face, neck
Chest: (2)
Extras
Complications (3)
**Peripheral Inspection**
* General
* Cachexia
* Hoarse voice or stridor
* Hands
* Clubbing ± HPOA (*Hypertrophic pulmonary osteoarthropathy)*
* Tar staining
* Claw hand c¯ wasting of interossei
* Face
* Anaemia
* Horner’s
* Plethora
* Neck
* LNs: check axilla too
* Dilated veins
**Chest**
* Thoracotomy scar
* Radiotherapy square burn + tattoo
* Acanthosis nigricans
1.Collapse
* Tracheal deviation towards lesion
* ↓ expansion
* PN: dull
* Auscultation
* ↓ or absent AE
* ± crackles
* ↑ VR
2. Effusion
* Tracheal deviation away
* ↓ expansion
* PN: stony dull
* Auscultation: ↓ AE
* ↓ VR
* *Extras:** *Hepatomegaly* or *spinal* tenderness
* *Complications**
1. SVCO
* Plethoric, oedematous face and upper limbs
* Dilated neck and chest veins
* Stridor
2. RLNP: hoarse voice c¯ bovine cough
3. Pancoast Tumour
* Horner’s
* Claw hand c¯ interossei wasting
4. Dermatomyositis
56
Lung conditions which includ lung cancer as a differential (3)
Consolidation
collapse
Effusion
57
Lobectomy/pneumonectomy
Examination
Peripheral inspection/chest/(pneumectomy vs lobectomy)/completion
* **Peripheral Inspection**
* Clubbing
* Cachexia
* **Chest**
* Scars
* Lateral thoracotomy
* Clamshell: double lung Tx
* Chest drains
* Chest wall asymmetry / deformity
* Pneumonectomy Vs Lobectomy:
* **Pneumonectomy**
* Tracheal *+ apex* shift to abnormal side
* Throughout normal sied:
* reduced expansion
* dull percussion
* **no** breath sounds
* **Lobectomy**
* Teacheal shift
* mainly upper lobectomy, therefore shift to abnormal side
* Focal signs
* reduced expansion
* dull percussion
* reduced breathsounds
* **Completion**
* ****history
* CXR
58
Differential for lateral thoracotomy scar
* Lobectomy
* Pneumonectomy
* Scar but normal lung
* Thoracotomy:
* abscess
* empyema
* biopsy
* wedge
* Transplant: ? other lung normal
59
Indications for lobectomy/pneumonectomy (4)
* 90% for non-disseminated _bronchial carcinoma_
* Other
* _Bronchiectasis_
* _COPD_: lung-reduction surgery
* _TB_: historic, upper lobe
60
Operative mortality for
lobectomy and pneumonectomy
Lobectomy: 7%
Pneumonectomy: 12%
61
Increased risk for lobectomy/pneumonectomy mortality (4)
* ↑ ASA grade
* Age \>70
* Poor resp function
* FEV1:FVC \<55%
62
Lung cancer
epidemiology (2)
* 3rd commonest malignancy in men and women
* Commonest cause of cancer death
63
Patholohy of lung cancer
| ('4 types')
* Non-Small Cell Lung Cancer
* **SCC**: 35%
* Highly related to smoking
* Centrally located
* PTHrP → ↑ Ca2+
* **Adenocarcinoma**: 25%
* RF: female non-smokers
* Peripherally located
* 80% present c¯ extrathoracic mets
* **Large-cell:** 10%
* **Small Cell Lung Cancer:** 20%
* Highly related to smoking
* Central location
* 80% present c¯ advanced disease
* Ectopic hormone secretion
64
Important History Qs in lung cancer pts (6)
* Symptoms
* Cough + haemoptysis
* Dyspnoea
* Chest pain
* Anorexia and wt. loss
* Smoking
* Occupational expose
65
Complications of lung cancer
Local (5)
Paraneoplastic (4)
Metastatic (4)
* **Local**
* Recurrent laryngeal N. palsy
* Phrenic N. palsy
* SVCO
* Horner’s (Pancoast’s tumour)
* AF
* **Paraneoplastic**
* Endo
* ADH → SIADH (euvolaemic ↓Na+)
* ACTH → Cushing’s syndrome
* Serotonin → carcinoid (flushing, diarrhoea)
* PTHrP → 1 HPT (↑Ca2+, bone pain) – SCC
* Rheum
* Dermatomyositis / polymyositis
* Neuro
* Cerebellar degeneration
* Peripheral neuropathy
* Derm
* Acanthosis nigricans
* Trousseau syndrome: thrombophlebitis migrans
* **Metastatic**
* Pathological #
* Hepatic failure
* Confusion, fits, focal neuro
* Addison’s
66
Investigations in lung Ca (5)
* *1. Bloods**
- FBC: anaemia, ↑WCC if consolidation
- U+E: ↓ Na (SIADH or Addison’s)
- LFTs: deranged LFTs 2 to liver mets
- Bone profile: ↑ Ca2+ (bone mets, ↑PTHrP)
* *2.** **Dx of Mass**
- CXR
- Coin lesions
- Effusion
- Consolidation or collapse
- Hilar LNs
- Bony mets
- Contrast-enhanced volumetric CT thorax
* *3. Determine Cell Type**
- Cytology
- Induced sputum
- US-guided pleurocentesis
- Histology
- Percutaneous FNA: adenocarcinoma
- Endoscopic transbronchial biopsy: SCC
* *4. Staging**
- CT: neck, thorax, upper abdo ± brain
- PET
- Radionucleotide bone scan
- Thoracoscopy, mediastinoscopy + LN sampling
* *5. Pulmonary Function Tests**
- Assess fitness for surgery
- Pneumonectomy CI if FEV1 \<1.2L
67
Management of lung ca
General
General
* MDT
* Stop smoking
* Optimise nutrition and CV function
68
Management of Ca
NSCLC specific: surgery, curative ration, chrmo
* *Surgery**
- Rx of choice if no metastatic spread (Stage 1/2:~25%)
- Wedge resection, lobectomy, pneumonectomy
* *Curative Radio:** if poor cardiorespiratory function
* *Chemo:** platinum-based + biologics
69
Management of lung Ca
SCLC specific (2)
* *Usually disseminated @ presentation*
* *Some benefit c¯ chemo*
70
Lung Ca management
Palliative care
(4)
* *Analgesia**: opiates for pain and cough
* *Radiotherapy**: haemoptysis, bone or CNS mets
* *SVCO**: dex + radio or intravascular stent
* *Persistent effusions:** chemical pleurodesis
71
Prognostic
NSCLC
SCLC
* NSCLC: 50% 5ys w/o spread; 10% c¯ spread
* SCLC: 1-1.5yrs median survival treated; 3mo untreated
72
Old TB Examination
Inspection/palpation/PN/ausc
Inspection
* Asymmetry: absent ribs
* Scars
* Thoracoplasty
* Supraclavicular fossa: phrenic nerve crush
Palpation
* Tracheal deviation towards apical fibrosis
* ↓ expansion
PN: dull
* Auscultation
* ± bronchial breathing
* ↓ AE
* Crackles
* ↑VR
73
Historical managament of TB
| (4)
*It was believed that lower **PAO2** would inhibit TB proliferation. THEREFORE -\> inducing apical collapse was a treatment*
Techniques
1. Plombage: insertion of polystyrene balls into thoracic cavity
2. Phrenic nerve crush: diaphragm paralysis
3. Thoracoplasty: rib removal to collapse lung
4. Apical lobectomy
74
Complications of old TB (3)
* Aspergilloma in old TB cavity
* Bronchiectasis
* LN compression of large airways
* Traction from fibrosis
* Scarring predisposed to bronchial Ca
75
Current management of TB
Initial Phase (RHZE): **2mos**
1. RMP: hepatitis, orange urine, enzyme induction
2. INH: peripheral sensory neuropathy, ↓PMN
3. PZA: hepatitis, arthralgia (CI: gout, porphyria)
4. EMB: optic neuritis → loss of colour vision first
Continuation Phase (RH): **4mos**
RMP
INH
76
Pathophysiology of primary TB
* Childhood or naïve TB infection
* Organism multiplies @ pleural surface → Ghon Focus
* Macros take TB to LNs
* Nodes + lung lesion = Ghon complex
* Mostly asympto: may → fever and effusion
* Cell mediated immunity / DTH controls infection in 95%
* Fibrosis of Ghon complex → calcified nodule (Ranke complex)
* Rarely may → 1O progressive TB (immunocomp)
77
Primary progressive TB pathophysiology
* Resembles acute bacterial pneumonia
* Mid and lower zone consolidation, effusions, hilar LNs
* Lymphohaematogenous spread → extra-pulmonary and milliary TB
78
Latent and secondary TB
Pathophysiology
**Latent TB**
* Infected but no clinical or x-ray signs of active TB
* Non-infectious
* May persist for years
* Weakened host resistance → reactivation
**Secondary TB**
* Usually reactivation of latent TB due to ↓ host immunity
* May be due to reinfection
* Typically develops in the upper lobes
* Hypersensitivity → tissue destruction → cavitation and formation of caseating granulomas.
79
Diagnosis ot TB
Latent/active
**Latent TB**
* Tuberculin Skin Test
* If +ve → IGRA
**Active TB**
* CXR
* Mainly upper lobes.
* Consolidation, cavitation, fibrosis, calcification
* If suggestive CXR take ≥3 sputum samples (one AM)
* May use BAL if can’t induce sputum
* Microscopy for AFB: Ziehl-Neelsen stain
* Culture: Lowenstein-Jensen media (Gold stand)
80
TB
PCR
* Can Dx rifampicin resistance
* May be used for sterile specimens
81
TB
Tuberculin skin test
* Intradermal injection of purified protein derivative
* Induration measured @ 48-72h
* False +ve: BCG, other mycobacteria, prev exposure
* False –ve: HIV, sarcoid, lymphoma
82
Inteferon Gamma Release Assays (IGRAs)
* Pt. lymphocytes incubated c¯ M. tb specific antigens → IFN-γ production if previous exposure.
* Will not be positive if just BCG (uses M. bovis) E.g. Quantiferon Gold and T-spot-TB
83
Pneumonia
Examination: peripheral inspection, chest, extras
**Peripheral Inspection**
* Ill looking
* Febrile
* ↑RR, ↑HR, AF
* Cough
* Rusty sputum
**Chest: Consolidation**
* ↓ expansion
* PN: dull
* Auscultation
* Bronchial breathing
* ↓ AE
* Focal coarse crackles
* Pleural rub
* ↑VR
**Extras**
* Para-pneumonic effusion
* Erythema multiforme: mycoplasma
84
Differntial for pneumonia (2)
Collapse
effusion
85
Important history Qs in pneumonia (4)
1. Symptoms
* Fever, rigors, anorexia, malaise
* Cough + sputum ± haemoptysis
* Pleurisy
2. Smoking
3. Travel and contacts
4. Immunosuppression: HIV, steroids
86
Investigation for pneumonia
bedside/bloods/CXR/other
* **Bedside**
* Sputum MC+S, cytology
* Urine
* Pneumococcal Ag
* Hb: cold agglutinins → haemolysis
* **Bloods**
* FBC: ↑ WCC
* U+E: dehydration, ↓Na
* CRP: trend
* LFT: ↑LFTs in mycoplasma, Legionella
* Culture: 25% positive
* Paired Sera: Mycoplasma, Chlamydia, Legionella
* ABG
* **CXR**
* Consolidation c¯ air bronchogram
* Effusion
* Cavities: esp. S. aureus
* **Other**
* Pleurocentesis
* BAL
87
Management of Pneumonia
2 principles
*Assess severity and Mx accordingly*
1. Specific
- Abx
- Analgesia
2. Supportive
- Oxygen
- Fluids
- Chest physio
88
Complications in pneumonia (4)
1. Septic *shock* + *MOF* (multiple organ failure) : ITU
2. Para-pneumonic *effusion* or *empyema*: drainage
3. Respiratory *failure*: ventilation
4. *Abscess*: drainage
89
Pneumonia follow up
| (3)
* *CXR @ 6 wks:** Check for underlying Ca and resolution
* *Smoking cessation**
* *Pneumovax** (23 valent) Re-vaccinate every **6yrs**
* ≥65yrs
* Chronic HLRP failure or conditions
* Immunosupp: DM, hyposplenism, chemo, HIV
90
incidence and mortality of pneumonia
* *Incidence**: 1/100
* *Mortality**: 10% in hospital, 30% in ITU
91
Anatomical Classification of pneumonia (2 types)
* *Bronchopneumonia**
- Patchy consolidation of different lobes
* *Lobar Pneumonia**
- Fibrosuppurative consolidation of a single lobe
- Congestion → red → grey → resolution
92
Aetiological classification of pneumonia (4)
**Community Acquired Pneumonia**
* Commonest organisms
* Pneumococcus: 50%
* Mycoplasma: 6%
* Haemophilus: esp. if COPD
* Chlamydia pneumonia
* Viruses: 15%
* Other organisms
* S. aureus
* Moraxella
* Legionella
* Rx: amoxicillin + clarithromycin
**Hospital Acquired Pneumonia**
\>48hrs after hospital admission
* Common organisms
* Pseudomonas
* MRSA
* Gm-ve enterobacteria
* Rx: co-amoxiclav or tazocin ± vanc
**Aspiration**
↑ Risk: stroke, bulbar palsy, ↓GCS, GORD, achalasia
* Typically posterior segment of RLL
* Orgnaisms: anaerobes
* Rx: co-amoxiclav
**Immunocompromised**
* PCP: co-trimoxazole
* TB: RIPE
* Fungi: amphotercin
* CMV/HSV: ganciclovir
93
Atypical pneumonia
* Refers to organisms which cause *_atypical generalised symptoms and bronchopneumonia_*
* Fever, headaches, myalgia
* Poor correlation between clinical and x-ray findings
* Often intracellular: *mycoplasma*, *Chlamydia, Legionella*
94
Severity scoring system for Pneumonia
**CURB-65** (only if x-ray changes)
* Confusion (AMT ≤8)
* Urea \>7mM
* Resp. rate \>30/min
* BP \<90/60
* ≥65
Score
* 0-1 → home Rx
* 2 → hospital Rx
* ≥ 3 → consider ITU
95
Inaddition to CURB-65
other markers of penumonia severity (5)
1. WCC: \<4 or \>12
2. Temp: \>38 or \<32
3. PaO2: \<8KPa
4. AF
5. Multiple lobar involvement
96
4 complications of pneumonia
1. Septic shock and MOF
2. Para-pneumonic effusion / empyema
3. Abscess: S. aureus, Klebsiella, anaerobes
4. Respiratory failure
97
What is
SIRS
sepsis
Severe spesis
septic shock
**Inflam response to a variety of insults manifest by ≥ 2 of:**
* Temperature: \>38°C or \<36°C
* Heart rate: \>90
* Respiratory rate: \>20 or PaCO2 \<4.6 KPa
* WCC: \>12x109/L or \<4 x109/L or \>10% bands
* *Sepsis:** SIRS caused by infection
* *Severe Sepsis:** Sepsis c¯ at least 1 organ dysfunction or hypoperfusion
* *Septic Shock:** Severe sepsis with refractory hypotension
98
MODS
What is multiple organ dysfunction syndrome?
*Impairment of ≥2 organ systems
Homeostasis cannot be maintained without therapeutic intervention.*
