Respiratory Flashcards
Pleural Effusion
Examination
(periph inspection, chest, significant negatives)
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
Differential of Dull Lung Base
- Consolidation: bronchial breathing + crackles
- Collapse: ↑ VR
- Pleural effusion
Causes of Pleural effusion
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
Pleural effusion Hx
Symptoms: SOB, pleurisy
Cause:
- Fever, sputum
- Smoking, wt. loss, haemoptysis
- Previous MI, orthopnoea, PND
- Hepatitis
Investigation of pleural effusion
- *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
Management of Pleural effusion
- 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
Bronchiectasis
Examination
(peripheral inspection, chest, extras, completion)
sig negatives and differentials
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
Causes of bronchiectasis
congenital/acquired
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
Bronchiectasis
Hx
Hx
- HPC: dyspnoea, cough, sputum, haemoptysis, wt. loss
- Cause: recurrent infections, arthritis, diarrhoea
- Smoking status
Bronchiectasis investigations
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
Bronchiectasis
Complications
- Cachexia
- Pulmonary HTN
- Massive haemoptysis
- Type 2 respiratory failure
- Amyloidosis
Management of Bronchiectasis
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
Cystic Fibrosis
Genetics, pathophysiology
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
CF Sx and Ix
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)
CF management
- *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
CF prognosis
Prognosis
- Mean survival 35yrs but rising
- Poorer prognosis if infected c¯ Burkholderia cepacia
PCD and Kartagener’s
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
Young’s Syndrome
- Bronchiectasis
- Rhinosinusitis
- Azoospermia (no sperm in semen) → ↓ fertility
Hypogammaglobulinaemia
(what/presentation/causes)
- 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
Yellow Nail Syndrome
- Very rare
- Yellow dystrophic nails
- Pleural effusions
- Lymphoedema: lymphatic hypoplasia
- Bronchiectasis
Allergic Bronchopulmonary Aspergillosis
(what/presentation/Ix/Rx)
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
Pulmonary fibrosis
peripheral inspection (gen/spec causes), chest, sig negatives
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
Pulmonary fibrosis
differential diagnosis
Bronchiectasis
chronic lung abscess
Pulmonary fibrosis
causes
Upper
lower (drugs; BANS ME)
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
Pulmonary fibrosis:
history Qs
- HPC: dyspnoea, cough, sputum, wt loss
- cause: arthritis, radiation, occupation, hobbies, DHx
- Smoking status
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
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
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*
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
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
- Airflow obstruction
- Specific
- Hands
- Tar staining
- CO2 retention flap
- Bounding pulse
- Face
- Plethora: ↑Hb
- Central cyanosis
- Hands
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
Differential for COPD patient (2)
- Chronic asthma
- Bronchiectasis
Key history Qs in COPD
(5)
- Symptoms: cough, sputum, dyspnoea
- Limitation: exercise tolerance
- Cause: smoking Hx, FHx
- Control: exacerbations, admissions
- Therapy: inhalers, vaccinations, home O2
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
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
- Acute
- Echo
- Cor pulmonale
Other
- 6 minute walk
- ECG: RVH
COPD classification
GOLD Classification: Global Initiative for Obstructive Lung Disease
Multidimensional classification to tailor therapy to pt.
Parameters
- mMRC dyspnoea score
- Airflow limitation
- 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 leave 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%
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
Management of COPD acute exacerbation
(and Ix: 4)
Ix
- PEFR
- Bloods: FBC, U+E, ABG, CRP, cultures
- Sputum culture
- CXR: infection, pneumothorax
Mortality
for in hospital COPD
15% in-hospital mortality
What to do on discharge following acute COPD exacerbation (6)
Discharge
- Spirometry
- Establish optimal maintenance therapy
- GP and specialist f/up
- Prevention using home oral steroids and Abx
- Pneumococcal and Flu vaccine
- Home assessment
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
Management of acute severe asthma
