Respiratory Flashcards
Respiratory causes of clubbing
- Idiopathic pulmonary fibrosis
- Lung cancer
- Suppurative lung diseases - cystic fibrosis, bronchiectasis, lung abscess
Causes of pulmonary fibrosis
- Idiopathic - CLUBBED!
- Drug induced
- Occupational lung disease
- coal miner’s lung: simple pneumoconiosis + progressive massive fibrosis - Associated with systemic disease
- Extrinsic allergic alveolitis
- Granulomatous disease - TB, sarcoid
- Radiotherapy
- Chemicals - steel, lead, paraquat
Systemic diseases that are associated with pulmonary fibrosis
All lower zone fibrosis EXCEPT Ank Spond
- RA
- And Spond
- Sjogrens
- UC
- Autoimmue thyroid disease
- Polymyositis
- Dermatomyositits
- Systemic sclerosis
Drugs that cause pulmonary fibrosis
- Immunosuppression:
- MTX
- Cyclophosphamide
- Sulphasalazine - Cardiac:
- Amiodarone - Antibiotics
- Nitrofurantoin - Chemotherapy
- Bleomycin
Different types of extrinsic allergic alveolitis
- Farmer’s lung
- Bird fancier’s lung
- Mushroom lung
Caplan’s syndrome
Coal miner’s lung + rheumatoid nodules
Clinical features of Sarcoidoisis by system
- Resp
- bilateral hilar lymphadenopathy
- pulmonary fibrosis - Skin
- erythema nodosum
- lupus pernio
- cutaneous sarcoid - Ophthal
- anterior uveitis
- keratoconjunctivitis sicca - Cardiac:
- conduction issues - ECG!! - Endocrine:
- hypercalcaemia - Neuro:
- bilateral facial nerve palsies
- psychosis - GI:
- hepatosplenomegaly
5 causes of cavitating lung lesions
Cancer Autoimmune e.g. granulomatosis with polyangiitis Vasculitis Infection - TB, staph, klebsiella Sarcoid
Causes of lower zone fine inspiratory crackles
Idiopathic pulmonary fibrosis Pulm fibrosis secondary to systemic conditions - RA - sjogrens - granulomatosis with polyangiitis - SLE - polymyositis/dermatomyositis
Causes of middle zone fine inspiratory crackles
Progressive massive fibrosis
Causes of upper zone fine inspiratory crackles
TB Ank Spond Radiotherapy Sarcoid Extrinsic allergic alveolitis
Causes of expiratory wheeze
Small Airway disease: Asthma COPD Churg-strauss (eosinophilic granulomatosis with polyangiitis) Aspirin Viral wheeze
Large airway disease
Epiglottitis
Foreign object
Pulmonary oedema
Causes of obstructive airway disease
COPD Asthma CF Bronchiectasis Alpha 1 anti-trypsin deficiency Obliteran bronchiolitis - follows lung transplantation with graft versus host disease, follows viral illness
7 classes of causes of bronchiectasis
- Genetic - cystic fibrosis
- Post infection
- Immune deficiency
- Mucociliary clearance abnormalities - primary ciliary dyskinesia
- Toxins - aspiration, inhalation
- Mechanical insults - foreign body, extrinsic lymph node compression intrinsic obstructing tumour
- Systemic disease associations
5 post infectious causes of bronchiectasis
- TB
- Whooping cough
- Severe pneumonia
- Non TB mycobacterium
- Allergic bronchopulmonary aspergillosis
2 immune deficiency causes of bronchiectasis
- Primary - hypogammaglobinuaemia
- Secondary
- HIV
- CLL
- Nephrotic syndrome
Primary ciliary dyskinesia - 6 features
- Autosomal recessive
- Situs invertus = Kartagener’s syndrome
- Persistent wet cough
- Hearing deficits
- Clubbing
- Infertility
6 systemic diseases associated with bronchiectasis
- SLE
- RA
- Sjogren’s
- Marfan’s
- IBD
- Chronic sinusitis
Bronchiectasis - further investigations
- CXR
- HRCT
- Sputum MC+S - specifically looking for S aureus, pseuomonas, haemophilus
- Serum Ig
- Sweat test
- Autoimmune antibody screen - anti-CCP, ANA, anti-Ro and anti-La
- Nasal brushings- Kartenger’s syndrome
- Tuberculin skin test, early morning
Clinical findings COPD
End of bed: - SOB - wheeze - inhaler Hands: - NO clubbing - tar stained fingers - CO2 retention flap (acutely unwell) - bounding pulse (CO2 retention) - peripheral cyanosis Arms: - nicotine patch - brusing secondary to long term steroid use Neck: - raised JVP if cor pulmonale Face: - cushing secondary to steroids Mouth; - central cynaosis - oral candiasis secondary in ICS - pursed lips Chest inspection - hyperinflated chest - use of accessory muscles - tracheal tug Chest percussion - hyper-resonate - reduced hepatic + cardiac dullness Chest ausculation - prolonged expiration - polyphonic wheeze - course crackles Legs - pedal oedema secondary to Cor Pulmonale
Extra:
Features of Cor Pulmomale - raised JVP, tricuspid regurgitation, peripheral oedema, hepatomegaly + pulsatile
Steroid use: cushing, bruising, buffalo hump, moon face
COPD - investigations
CXR
Sputum MC+S
Peak flow
Spirometry
- obstructive picture without reversibility
Alpha 1 anti-trypsin levels
Bloods - FBC (polycythaemia), albumin (chronic disease)
Smoking cessation options
- Behavioural treatment
- Nicotine replacement therapy including vaping
- Buproprion
COPD treatment
- Stop smoking
- Inhalation therapies
- beta agonist - short acting + long acting
- antimuscurinic - short (ipratropium) + long (tiotropium)
- steroid - Mucolytics
- Oral steroids
- Theophylline
- LTOT
- Pulmonary rehab
- NIV
- Surgery - lung reduction to remove bullae
- Lung transplant
Clinical findings bronchiectasis
End of bed: - SOB - productive cough - cachetic Hands: - clubbing - cyanosis - bruising secondary steroids - rheumatoid hands - tar staining --> lung cancer --> bronchiectasis Arms: - bruising - PICC line - long term Abx Neck: - raised JVP 2nd to Cor Pulmonale - lymphadenopathy 2nd leukaemia/HIV Face: - periorbital oedema - Nephrotic syndrome - moon face --> cushing --> steroid use - Horner's syndrome (meiosis, ptosis, anhydrosis) --> lung cancer Mouth: - high arched palate - Marfan's - ulcers - IBD - angular stomatitis --> B12 deficiency --> IBD Chest inspection: - thoracoomy --> lung Ca, lung abscess - hyperexpanded Chest percussion - hyper-resonant Chest ausculation - inspiratory crackles - course, late - expiratory wheeze Heart sounds - Dextrocardia!
Congenital causes of bronchiectasis
- Cystic fibrosis
- Yellow nail syndrome - yellow nails, pleural effusion, lymphoedema
- Kartenger’s syndrome
Young’s syndrome - similar to CF but no CF mutation - appears in middle aged men
Management of CF
General measures:
- Optimize nutrition
- calorie supplement
- pancreatic enzyme - Stop smoking
- Vaccinations
- Sputum clearance physiotherapy
Medical treatment:
- Antibiotics - cover pseudomonas
- may need prophylactic - Bronchodilators
- Inhaled steroids
- Mucolytics
- Genetic treatment - introduction of normal CFTR gene
Pathogenesis of CF
Mutation in CFTR gene - loss of chloride movement across cell membranes - raises osmotic pressure inside cells keeping extracellular space dehydrated - thick mucous production
Which system affected by CF
- Respiratory
- Endocrine pancreas - type 1 diabetes
- Exocrine pancreas - malabsorption
- Focal biliary cirrhosis
Complications of bronchiectasis
Pulmonary
- Haemoptysis
- Recurrent infections
- Empyema/abscess
- Cor pulmonale
Extra-pulmonary
- Metastatic infections
- Anaemia
- Secondary amyloidosis
Old TB clinical findings
End of bed:
- not SOB
Hands:
- not clubbed
Arms:
- nil
Neck:
- supra-clavicular scar from phrenic crush
Face:
- nil
Mouth;
- nil
Chest inspection
- thoracotomy scars
- rib resections
- chest deformity
- tracheal deviation TOWARDS side of thoracotomy scar
- reduced expansion on side of resection
Chest percussion
- dullness to percuss over resection
Chest ausculation
- bronchial breathing over resection site
- fine end inspiratory crepitations due to fibrosis
OR course inspiratory crackles due to bronchiectasis
EXTRA
- kyphosis may be sign of spinal TB (Pott’s disease)
TB investigations
- CXR
- HRCT
- Sputum for Ziehl-Neelson staining - acid fast bacilli. Need 3 samples
- Early morning urine for AFB - x3 consecutive samples
- Mantoux test
- injection of TB - assess for type 4 hypersensitivity
FALSE negatives in immunosuppressed - HIV test
- Bronchoscopy for BAL
TB risk factors
- Place of birth
- Age
- HIV
- Homeless
- Sex worker
- Co-morbidities e.g. diabetes
- Immunosuppression - anti-TNF medications
Pulmonary fibrosis - investigations
- Laboratory:
- ABG - hypoxia + hypocapnia (secondary to hyperventilation
- Eosinophilia - Eosinophilic granulomatosis with polyangiitis
- ANA —> SLE
- anti-CCP/RA –> RA
- anti-centromere antibody –> limited systemic sclerosis
- anti-Scl 70 –> diffuse systemic sclerosis
- anti Jo1 –> dermatomyositis
- serum immunoglobulins –> bronchiectasis secondary to immunoglobulin deficiency (primary or secondary), IgE for ABPA
- serum ACE –> sarcoid
- CK –> myositis - Functional tests
- lung function tests with diffusion capacity
- -> restrictive pattern with reduced diffusion capacity (indicates loss of alveolar function)
- 6 minute walk test - Radiological
- HRCT - Echo
- assess pulmonary artery pressures - Bronchoscopy
- BAL +/- biopsy
What is Hammah Rich Syndrome
Acute rapidly progressive lung fibrosis also known as acute interstitial pneumonia
Rheumatoid arthritis pulmonary manifestations
- Rheumatoid nodules
- mainly asymptomatic
- can become infected - Pleurisy/pleural effusions
- RF +ve effusions - Fibrotic lung disease
- lower zone
Clinical features of pleural effusion
End of bed: - SOB - cachetic ?malignancy - cough Hands: - malignancy: clubbing, tar stains, wasting of small muscles of hand (pancoast tumour - T1 paralysis) - RA: rheumatoid hands. Arms: - dialysis access Neck: - raised JVP - SVCO obstruction, heart failure - lymphadenopathy - if present then palpate for axillary LNs - goitre: hypothyroidism - dialysis access
Face:
- SLE - butterfly rash
- peri-orbital oedema –> nephrotic syndrome
Mouth;
- mucositis - on chemo
Chest inspection
- radiotherapy tattoos
- mastectomy
- spider naevi - hypoalbuminaemia secondary to liver disease
- trachea deviated away from effusion (large volumes)
- reduced chest expansion
Chest percussion
- dull to percuss
Chest ausculation
- reduced air entry +/- crackles
- reduced vocal resonance
Define Light’s criteria for pleural effusion
Exudative effusion if one of the following:
- Pleural protein: serum protein >0.5
- Pleural LDH: pleural LDH >0.6
- Pleural LDH >0.6 or 2/3 of normal upper limit of serum LDH
Caveats with Lights criteria and further calculation to perform
20-25% of patients with transudative effusions diagnosed as exudates
If you think patient has transudate i.e. has CCF but Lights criteria is positive for exudate then perform following calculation:
serum albumin - pleural albumin
if >1.2g/dL then = transudate
Management of pleural effusion
- Supportive
- oxygen - Treat underlying cause
- antibiotics
- diuretics - Pleural drainage under USS guidance
- Pleurodesis if recurrent
- medical via pleural drain
- surgically via VATS - Long term pleural drain i.e. malignancy
- Pleural-peritoneal shunt
Pleural effusion classifications
- Transudate
- Exudate
- Haemothorax
- Chylothorax
- Empyema
- Drug induced pleural effusions
Drugs that can cause pleural effusion
- Drugs associated with drug-induced lupus e.g. quinidine, procainamide, anti-TNF,
- Dopamine agonist - bromocriptine
- DMARDS e.g. MTX
- Anti-migraine - methysergide
- Antibiotics - nitrofurantoin
- Chemotherapy - procarbazine
3 types of pneumothorax
- Traumatic
- Spontaneous
- primary (no lung disease) - tall young men, Marfan’s
- secondary (lung disease) - COPD, asthma - Tension pneumothorax
Obesity hypoventilation syndrome/Pickwickian syndrome
- 3 components
- Obstructive sleep apnoea
- Hypercapnia
- Restrictive pulmonary function test
Clinical features of Pickwickian syndrome
End of bed: - obese -dyspnoeic - sleepy - shallow breathing Hands: - nil obvious Arms: - check for raised BP Neck: - large neck circumference - raised JVP secondary to pulmonary hypertension Face: - facial plethora - due to secondary polycythaemia Mouth; - maxillary/mandibular hypoplasia - crowded oropharynx Chest inspection - features of pulmonary hypertension with heart failure
Chest percussion
- features of pulmonary hypertension with heart failure
Chest ausculation
- features of pulmonary hypertension with heart failure
Complications of direct lung cancer extension
- Hoarse voice - recurrent laryngeal nerve palsy
- Stridor - tracheal invasion
- Horner’s syndrome + weakness/atrophy of intrinsic small muscles of hand - Pancoast tumour invading in to paravertebral sympathetic chain
- Superior vena cava obstruction
Paraneoplastic malignancy syndromes by system
- MSK
- Hypertrophic pulmonary osteoarthropathy
- Polymyositis - Neurological
- Lambert Eaton myasthenic syndrome - associated with small cell lung cancer
- Proximal myopathy
- Cerebellar syndrome
- Peripheral neuropathy - Endocrine
- Hypercalcaemia
- SIADH
- Ectopic ACTH secretion –> cushing’s, pigmentation. - Dermatological
- Thrombophlebitis migrans
- Acanthosis nigrans
- Dermatomyositis
Superior vena cava obstruction - Clinical findings
End of bed:
- SOB
- hoarse voice - tumour invasion in to recurrent laryngeal nerve
- stridor - tumour invasion into upper airway
- cachectic
Hands:
- clubbing - cancer
- tar stains - smoking –> cancer
- wasting of small muscles of hand –> pancoast tumour
Arms:
- ?PICC line - on chemo
Neck:
- Fixed raised JVP
- distended superficial neck veins
Face:
- facial plethora
- odematous
- suffusion of eyes
- PEMBERTON’S SIGN* - symptoms get worse if raise arms above head
Mouth;
- nil obvious
Chest inspection
- thoracotomy scars
- radiotherapy tattoos
- engorged chest veins
- mastectomy
Chest percussion
- ?pleural effusion/dullness
Chest ausculation
- crackles/reduced air entry etc ?cancer ?lung resection ?previous radiotherapy
Common causes of SVCO
Right lung pathology
- lung cancer
- lymphoma
Lymph nodes
- metastatic LNs
- primary lymphoproliferative diseases
Mediastinal pathology:
- thymoma
- mediastinal germ cell cancers
- thoracic artery aneurysm
SVC intrinsic pathology
- stenosis or thrombosis following central line, pacemaker lines, etc
Management of SCVO
- ABC
- Steroids in malignancy
- SCVO stenting under IR
- Radiotherapy
- Chemo if chemo sensitive i.e. small cell, lymphoma
Thoracotomy scars - clues for underlying diagnosis
- Old TB - Phrenic nerve crush scar - supraclavicular
- Lung cancer - clubbing, tar stains, inhaler for COPD, radiotherapy tattoo, radiotherapy burns.
- Bronchiectasis - clubbing, sputum pot, productive cough, coarse crackles
Reasons to perform a pneumectomy or lobectomy
- Resection of malignancy
- primary NSCLC
- solitary metastases - Infections:
- Old TB - prior to modern anti-TB medications
- Aspergilloma - Bullectomy for large empyseamtous bullae
- Localised bronchiectasis with uncontrolled symptoms e.g. haemoptysis
Treatment of asthma
Step wise approach as per BTS
- Inhaled short acting beta 2 agonist
- Inhaled steroids
- Inhaled steroids + long acting beta 2 agonist
- Leukotriene antagonist - montelukast
Differentiate between asthma and COPD
- Smoking history
- Spirometry - reversibility of obstructive picture
- change in PEF and/or FEV1 in response to inhaled beta 2 agonist
- 200ml change in FEV1 or 15% change in comparison to baseline - Age
Investigations for asthma
- Bloods - eosinophil count and IgE level
- Peak flow diary looking for diurnal variation
- Spirometry - obstructive picture (decreased FEV1 and preserved FVC with reduced ratio <0.8) that is reversible
Benefits of VATS over thoracotomy
- Reduced pain
- Reduce healing time
- Reduced hospital length of stay
FVC limits for 1) lobectomy 2) pneumonectomy
1) >1.5L 2) >2L
Lung transplant clinical findings
- Clam shell scar
- Multiple chest drain site
- Possible tracheostomy scars
- CVC scars
Indications for lung transplant
- Bronchiectasis
- Idiopathic lung fibrosis
- Pulmonary vascular disease
- COPD
Complications of lung transplant
Rejection (acute and chronic) including bronchiolitis obliterans syndrome
Infection e.g. CMV, HSV, aspergillus, PCP, bacterial pneumonia
Immunosuppression therapy side effects
