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
Tool to predict mortality in COPD
BODE Index (4)
Multidimensional tool to predict mortality in COPD
Uses multiple independent risk factors
- BMI
- Obstruction: FEV1
- Dyspnoea: MRC score
- Exercise capacity: 6 min walk
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
Key history Qs in asthma Pt (6)
- Symptoms: cough, dyspnoea, wheeze, diurnal variation
- Limitations: exercise, sleep, work
- Cause: atopy, exercise, cold, smoking
- Control: SABA use, attacks, admissions, ITU
- Check peak flow diary
- Therapy: oral steroid use, check inhaler technique
- Assocs.
- GORD: dyspepsia
- Churg-Strauss: recent onset, rash, neuropathy
Definition of asthma
Episodic, reversible airway obstruction due to bronchial
hyper-reactivity to a variety of stimuli.
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
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
Features of well controlled asthma (5)
- No exacerbations
- No reliever therapy: no PRN salbutamol
- No night time waking
- <20% diurnal variation
- Normal lung function
Key Hx Qs in acute severe asthma (4)
- Precipitant: infection, travel, exercise?
- Usual and recent Rx?
- Previous attacks and severity: ICU?
- Best PEFR?
AMPLE
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
Features of severe asthma (4)
- PEFR <50%
- Can’t complete sentence in one breath
- RR >25
- HR >110
Features of life threatening asthma (7)
- PEFR <33%
- SpO2 <92%, PCO2 >4.6kPa, PaO2 <8kPa
- Cyanosis
- Hypotension
- Exhaustion, confusion
- Silent chest, poor respiratory effort
- Tachy-/brady-/arrhythmias
Differential of Acute severe asthma
Presents as: ‘acute breathlessness and wheeze’
- pneumothorax
- acute exacerbation of COPD
- Pulmonary oedema
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
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
Management of acute severe asthma
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
- Effusion
- Tracheal deviation away
- ↓ expansion
- PN: stony dull
- Auscultation: ↓ AE
- ↓ VR
- *Extras:** Hepatomegaly or spinal tenderness
- *Complications**
- SVCO
- Plethoric, oedematous face and upper limbs
- Dilated neck and chest veins
- Stridor
- RLNP: hoarse voice c¯ bovine cough
- Pancoast Tumour
- Horner’s
- Claw hand c¯ interossei wasting
- Dermatomyositis
Lung conditions which includ lung cancer as a differential (3)
Consolidation
collapse
Effusion
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
- Scars
- 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
- Teacheal shift
-
Pneumonectomy
-
Completion
- history
- CXR
Differential for lateral thoracotomy scar
- Lobectomy
- Pneumonectomy
- Scar but normal lung
- Thoracotomy:
- abscess
- empyema
- biopsy
- wedge
- Transplant: ? other lung normal
- Thoracotomy:
Indications for lobectomy/pneumonectomy (4)
- 90% for non-disseminated bronchial carcinoma
- Other
- Bronchiectasis
- COPD: lung-reduction surgery
- TB: historic, upper lobe
Operative mortality for
lobectomy and pneumonectomy
Lobectomy: 7%
Pneumonectomy: 12%
Increased risk for lobectomy/pneumonectomy mortality (4)
- ↑ ASA grade
- Age >70
- Poor resp function
- FEV1:FVC <55%
Lung cancer
epidemiology (2)
- 3rd commonest malignancy in men and women
- Commonest cause of cancer death
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%
-
SCC: 35%
-
Small Cell Lung Cancer: 20%
- Highly related to smoking
- Central location
- 80% present c¯ advanced disease
- Ectopic hormone secretion
Important History Qs in lung cancer pts (6)
- Symptoms
- Cough + haemoptysis
- Dyspnoea
- Chest pain
- Anorexia and wt. loss
- Smoking
- Occupational expose
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
- Endo
-
Metastatic
- Pathological #
- Hepatic failure
- Confusion, fits, focal neuro
- Addison’s
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
Management of lung ca
General
General
- MDT
- Stop smoking
- Optimise nutrition and CV function
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
Management of lung Ca
SCLC specific (2)
- Usually disseminated @ presentation
- Some benefit c¯ chemo
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
Prognostic
NSCLC
SCLC
- NSCLC: 50% 5ys w/o spread; 10% c¯ spread
- SCLC: 1-1.5yrs median survival treated; 3mo untreated
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
Historical managament of TB
(4)
It was believed that lower PAO2 would inhibit TB proliferation. THEREFORE -> inducing apical collapse was a treatment
Techniques
- Plombage: insertion of polystyrene balls into thoracic cavity
- Phrenic nerve crush: diaphragm paralysis
- Thoracoplasty: rib removal to collapse lung
- Apical lobectomy
Complications of old TB (3)
- Aspergilloma in old TB cavity
- Bronchiectasis
- LN compression of large airways
- Traction from fibrosis
- Scarring predisposed to bronchial Ca
Current management of TB
Initial Phase (RHZE): 2mos
- RMP: hepatitis, orange urine, enzyme induction
- INH: peripheral sensory neuropathy, ↓PMN
- PZA: hepatitis, arthralgia (CI: gout, porphyria)
- EMB: optic neuritis → loss of colour vision first
Continuation Phase (RH): 4mos
RMP
INH
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)
Primary progressive TB pathophysiology
- Resembles acute bacterial pneumonia
- Mid and lower zone consolidation, effusions, hilar LNs
- Lymphohaematogenous spread → extra-pulmonary and milliary TB
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.
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)
TB
PCR
- Can Dx rifampicin resistance
- May be used for sterile specimens
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
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
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
Differntial for pneumonia (2)
Collapse
effusion
Important history Qs in pneumonia (4)
- Symptoms
- Fever, rigors, anorexia, malaise
- Cough + sputum ± haemoptysis
- Pleurisy
- Smoking
- Travel and contacts
- Immunosuppression: HIV, steroids
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
Management of Pneumonia
2 principles
Assess severity and Mx accordingly
- Specific
- Abx
- Analgesia - Supportive
- Oxygen
- Fluids
- Chest physio
Complications in pneumonia (4)
- Septic shock + MOF (multiple organ failure) : ITU
- Para-pneumonic effusion or empyema: drainage
- Respiratory failure: ventilation
- Abscess: drainage
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
incidence and mortality of pneumonia
- *Incidence**: 1/100
- *Mortality**: 10% in hospital, 30% in ITU
Anatomical Classification of pneumonia (2 types)
- *Bronchopneumonia**
- Patchy consolidation of different lobes
- *Lobar Pneumonia**
- Fibrosuppurative consolidation of a single lobe
- Congestion → red → grey → resolution
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
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
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
Inaddition to CURB-65
other markers of penumonia severity (5)
- WCC: <4 or >12
- Temp: >38 or <32
- PaO2: <8KPa
- AF
- Multiple lobar involvement
4 complications of pneumonia
- Septic shock and MOF
- Para-pneumonic effusion / empyema
- Abscess: S. aureus, Klebsiella, anaerobes
- Respiratory failure
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
MODS
What is multiple organ dysfunction syndrome?
Impairment of ≥2 organ systems
Homeostasis cannot be maintained without therapeutic intervention.
