Respiratory Flashcards
Interstitial Lung Disease
What are the causes of interstitial lung disease?
- Idiopathic (IPF/Cryptogenic fibrosing alveolitis)
- Inhaled agents (Hypersenitivity pneumonitis/EAA, Astestosis, Berylliosis, Silicosis)
- Rheumatological (RA, SLE, SS sclerosis, DM, PM, MCTD, Ankylosing spondylitis)
- Vasculitic (PAN, GPA, EGPA)
- Granulomatous (Sarcoidosis)
- Infectious (TB, ABPA)
- Drugs (Amiodarone, Nitrofurantoin, Busulphan, Bleomycin, Methotrexate)
- Radiation
- Genetic (NF, Tuberous sclerosis)
Interstitial Lung Disease
What are the causes of apical fibrosis?
SCHART
- Silicosis, Sarcoidosis
- Coal Worker’s Pneumoconiosis
- Histiocytosis
- Ankylosing Spondylitis, ABPA
- Radiation
- Tuberculosis
Interstitial Lung Disease
What are the causes of basal fibrosis?
RASIO
- Rheumatoid Arthritis
- Asbestosis
- Systemi Sclerosis
- Idiopathic pulmonary fibrosis and Hamman-Rich syndrome
- Other (Drugs: busulphan, bleomycin, nitrofurantoin, hydralazine, MTX, amiodarone)
Pleural Effusion
What are Light’s Criteria?
Light’s criteria for an exudate:
1)Pleural protein: Serum protein >0.5
2)Pleural LDH: Serum LDH >0.6
3)Pleural LDH >2/3 upper limit of normal serum value
Require 1 criteria to diagnose as exudate
Pleural Effusion
What are the causes of an exudative pleural effusion?
- Infection: Pneumonia, Tuberculosis.
- Inflammation: :RA, SLE, Sarcoidosis.
- Ischaemia/Infarction: PE
- Malignancy: Lung carcinoma, Mesothelioma, Secondary malignancy, Lymphoma, Meig’s syndrome (ovarian fibroma).
- Drugs: Methysergide, Methotrexate, Bromocriptine, Nitrofurantoin
Pleural effusion
What are the causes of a transudative pleural effusion?
- Cardiac: CCF, Constrictive pericarditis
- Liver: Cirrhosis, Hypoalbuminaemia
- Renal: Nephrotic syndrome, Uraemia.
- Hypothyroidism
Pleural Effusion
What are the criteria for a complicated parapneumonic pleural effusion?
A complicated parapneumonic effusion requires chest drainage:
- > 50% Hemithorax
- Loculated
- Turbid
- pH < 7.2
- LDH >1000
- Glucose <3.4
Pleural Effusion
What are the criteria for an empyema?
An empyema requires chest drainage:
- Positive culture
- Frank pus on pleural tap
- > 50% Hemithorax
- pH <7.2
- LDH >1000
- Glucose <3.4
Bronchiectasis
What are the causes of bronchiectasis?
- Respiratory Childhood Infections: Measles, Pneumonia, TB, ABPA
- Bronchial Obstruction: Foreign body, Endobronchial tumour
- Immunodeficiency: Congenital & Acquired Hypogammaglobulinaemia, AIDS
- Autoimmune Diseases, RA, SS, IBD
- Mucociliary Clearance Defects: CF, Immotile cilia syndrome, Kartagener’s syndrome, Young syndrome, Yellow Nail Syndrome
SVC Obstruction
What are the causes of SVC obstruction?
- Malignancy: Lymphoma (NHL>HL), Bronchial carcinoma (SCLC)
- Mediastinal Masses: Goitre, Thymoma, Mediastinal fibrosis, Thoracic aortic aneurysm
- Central Venous Thrombosis: Complication of central venous catheters, Thrombophilic disorders
Lung Consolidation
What are the causes of a cavitating lung lesion?
Infection, Malignancy, Vasculitis
- Infection/lung abscess: TB, Aspergilloma, Histoplasmosis, Coccidiomycosis, Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, Anaerobic infections
- Non-Infectious: Malignancy, GPA, Pulmonary rheumatoid nodule, Caplan’s syndrome
What are the clinical features of sarcoidosis?
Systemic: fever, wt loss
Pulmonary: cough, sob, nasal congestion
CXR: hilar lymphadenopathy, pulmonary fibrosis
Eye: uveitis
Skin/arthralgia: erythema nodosum; lupus pernio nose
Nerve: neuropathy/palsied; facial nerve palsy
Cardiac: arrhythmia
Investigations for sarcoidosis?
- FBC: lymphocytopenia, eosinophilia
- ESR
- ACE level
- CXR, CT chest
- PFT, ABG
- bronchoscopy and biopsy
- LN biopsy
Treatment for sarcoidosis?
- indications: - increasing symptoms, worsening lung function, Neuro/renal/cardiac/eye complications
- prednisone 1mg/kg 1 yr taper
- if long term Rx needed: MTX, AZA
- hydroxychloroquine for skin disease
- infliximab: 3rd line
What are causes of clubbing?
- resp: lung ca, bronchiectasis, CF, Idiopathic pulmonary fibrosis
- cardiac: cyanotic congenital heart disease, IE
- GI: cirrhosis, IBD, Coeliac
- thyrotoxicosis
What us the differential for bilateral crackles?
- pulmonary edema/cardiac failure
- bronchiectasis
- atelectasis
- bilateral pneumonia
- pulmonary fibrosis (fine crackles)
What is the differential for a lung mass on imaging?
- carcinoma - primary or metastatic
- lung abscess
- TB
- pulmonary infarct
- granuloma: I.e. Fungal
What are the signs of asthma severity?
- symptoms throughout day
- nightly symptoms >7x/week
- SABA use several times a day
- extreme interference with normal activity
- FEV1
How to investigate asthma?
- spirometry: obstructive, reversible 12%
- bronchial challenge testing if normal spiro
- PEF for monitoring
- allergen skin testing
How would you manage asthma? (Maintenance Rx)
Non pharm: - allergen avoidance, smoking cessation - asthma action plan Pharm: - vaccinations - SABA - ICS alone - ICS/LABA combination - prednisone - treat GORD, if present
How to diagnose sleep apnea?
- sleep study: apnea-hypopnea index (severe >60)
- ABG
What is the PAP for dx of pulmonary HTN?
> 25 at rest
Or
30 with exercise
What investigations for pulmonary HTN?
- CXR
- PFT
- ECG
- ABG
- CTPA or VQ
- HRCT
- TTE
- R heart cath
- 6min walk test
What are the types/classes of pulm HTN?
- Pulmonary arterial HTN
- From L heart disease
- Due to lung disease
- Due to chronic PE
- Unclear multifactorial mechanisms
How to determine pharmacological treatment in pulm HTN?
If reversibility: calcium channel blockers Otherwise, - endothelin receptor antag: bosentan - PDE5i: sildafenil - prostacyclins: iloprost, epoprostenol
What gene and chromosome involved with CF?
Autosomal recessive CFTR gene mutation
(Most common is delta F508)
Chromosome 7
1:25 carrier rate
What are the various manifestations of CF?
- GI baby: meconium ileum, failure to thrive
- Resp: cough, haemoptysis, wheeze, SOB
- Cardiac: cor pulmonale
- Gastro: diarrhea, steatorrhea, pancreatic insufficiency, intestinal obstruction, ADEK deficiency
- Liver: cirrhosis/fibrosis, cholelithiasis
- DM
- infertility: CBAVD
What organisms associated with CF?
- Staph and h. influenzae
- Nosocomial e.coli and proteus
- Pseudomonas***
- Burkholderia = poor prognosis
What investigations for CF?
- sputum MCS
- bloods: FBC (anaemia, infection), LFT/alb, coags
- CXR
- CT chest
- PFT
What is your management of pulmonary CF?
- neb. Antibiotics (tobramycin)
- bronchodilators
- mucolytics: neb NS, DNase
- mutation specific drugs: ivacaftor(G551D), lumacaftor-ivacaftor(DF508)
Non Pharm: - postural drainage, chest Physio
- medical devices: oscillating devices
- exercise
What is indication for lung transplant in CF?
-FEV1 <30%; Severe hypoxaemia &/or hypercapnoea
-Increasing functional impairment (↑ing frequency & duration hospitalisations)
-Major life-‐threatening pulmonary complns (e.g. recurrent massive haemoptysis)
-Also: If 5-‐year survival <30% - clear survival benefit; if 30-50% equivocal; and >50% no benefit apart from QOL
>Contraindications:
- Cx infection with Burkholderia cenocepacia MDR Pseudomonas
-Intubated patients in Acute Resp failure
-Symptomatic osteoporosis (relative Contraind)
How would you manage gastro manifestations of CF?
- high protein/fat diet
- nutritional supplements
- pancreatic enzyme replacement
How do you manage pregnancy with CF?
- acknowledge fertility issues; in women, mainly due to malnutrition
- if FEV1 > 60%, should be OK
- pulmonary HTN is contraindication to pregnancy
- genetic counselling
- screen for GDM
- increased prematurity
How would you approach pre transplant work up?
Lungs: PFT, imaging, 6MWT
Heart: TTE, ECG, angio, R heart cath
Infection status: CMV, EBV, HIV, Hep, sputum
Vaccinations
Malignancy: 5yrs cancer free
Social/mental: psych review, social supports, living, finance, compliance
Education
