Respiratory Flashcards
VATS lobectomy Indications Benefits Signs on examination FEV1 Vmax
Indications
Lung malignancy
Infection - TB, Aspergilloma, Lung abscess
Bronchiectasis with recurrent sx and haemoptysis
Benefits of VATS
Minimally invasive
Reduced rates of wound complication
Quicker healing time and length of stay
Signs on examination
Triangulation scars with one largest (3-4cm)
Recent - reduced signs over lobe
Historic - normal lung exam
FEV1 - >1.5L
Vmax - 15ml/kg/min
Causes of consolidation
Pneumonia
Malignancy
Pulmonary infarct
Causes of obstructive spirometry
COPD
Asthma
Bronciectasis
Obliterative bronchiolitis
Causes of ILD
Idiopathic pulmonary fibrosis Connective tissue disease RA Sarcoidosis TB
Causes of basal lung fibrosis
Drugs Asbestosis RA Sclerosis / CTD Idiopathic pulmonary fibrosis
Causes of pul htn
Primary pul htn
Secondary:
Pulmonary vascular disease - Recurrent PEs, schistosomiasis, autoimmune (ILD)
Acquired heart disease - valvular, cardiomyopathy, CCF
Congenital heart disease - ASD, VSD, PDA
Structural lung disease: COPD, CF
Non-pulmonary causes of alveolar hypoventilation - kyphoscoliosis, Pickwickian, neuromuscular weakness.
Mx of bronchiectasis
Conservative - stop smoking, vaccination, postural drainage and breathing exercises, chest physiotherapy
Medical - bronchodilators, saline nets, mucolytics, inhaled abx. 2/52 abx for any infection, long term abx (azithromycin). LTOT
Surgical - lobectomy, pneumonectomy, double lung transplant, bronchial artery embolisation for haemoptysis
VATS scar
Indications
Lobectomy Pneumonectomy Wedge resection Decortication Bullectomy Persistent air leak of pneumothroax
Causes of collapse / atelectasis
Acute - mucous plugging, chest wall / rib injury, foreign body
Sub acute - obstructing neoplasm, post op
Chronic - fibrotic change, bronchiectasis, diaphragmatic palsy
Lung manifestations of RA
ILD - fibrosing alveolitis
RA-associated pleural effusion
Obliterative bronchiolitis
Pulmonary nodules
Treatment of cystic fibrosis
MDT
Cause and complications
GI:
Creon and nutritional support
Laxatives
Resp: Abx Mucolytics Chest physiotherapy for mucous clearance Inhaled therapies
Endocrine
Insulin
Cause:
Lumacaftor / ivacaftor to promote CFTR presence and function
Surgical - double lung transplant
Causes of a SVC obstruction
Malignancy - Lung carcinoma, Lymphoma
CV - Aortic aneurysm
Mediastinal fibrosis
Thyroid - Goitre
What are the features of EAA
Acute pulmonary and systemic sx occurring post allergen exposure
Pulmonary: Cough, wheeze, chest tightness
Systemic: fever, fatigue, myalgia
Sx occur within 4-12hrs of exposure and settle when not exposed
Type III antigen/antibody response but can progress to granulomatous inflammation
Chronic exposure can cause an organising pneumonia and obliterative bronchiolitis and fibrotic change
Common triggers - hay, mould, bird antigens
What would you expect to see on spirometry of someone with COPD?
How is it classified
FEV1/FCC <70%
Total lung capacity and residual volume increased
Decreased transfer factor
FEV1 >80% predicted - mild
FEV1 50-80% predicted - moderate
FEV1 30-50% predicted - severe
FEV1 <30% predicted - very severe
Ddx of pleural effusion (dull lung base)
Raised hemidiapharagm
Basal collapse
Pleural thickening - TB, mesothelioma
Pattern of spirometry in ILD
Restrictive
Reduced FEV1 and FVC with preserved ratio (>0.7)
Reduced total lung capacity and transfer factor
Pul art pressure to dx pul htn
Causes
Mx
> 25mmHg at rest or >30 on exertion
PCWP <15 indicates primary pul htn, not due to CCF
Causes: Primary Chronic hypoxia (causes vasoconstriction) Chronic PEs CCF ARDS ILD Eisenmengers post shunt Hypoventilation
Mx:
Vasodilator challenge - prostacyclin infusion/inhalation
If +ve response - CCB (nifedipine, diltiazem)
If -ve response - prostacyclin analogues (iloprost), endothelia antagonist (bosentan), PDEi (sildenafil)
Diuresis
Anticoagulation
CXR signs of pneumonectomy
White out on one side with trachea devoted toward the white out (vs effusion - pushed)
Investigation of a pt with suspected lung ca
Hx and examination CXR CT CAP +/- PET CT (functional imaging) Lung function testing Tissue diagnosis - throacoscopy, bronchoscopy +/- EBUS, CT-guided biopsy Preparation for surgery - echo
Indications for lung transplant
Criteria:
Severe / end stage disease - >50% risk of death from lung disease within 2yrs without transplant
Good functional baseline / co-morbidities - >80% chance surviving 90 days post transplant
>80% chance of 5yr survival from general medical conditions
1 - lung vascular disease - pul htn (primary or due to systemic disease), Eisenmenger’s syndrome,e
2 - interstitial lung disease - idiopathic fibrosis, fibrosis due to connective tissue disease, sarcoidosis, chronic allergic alveolitis
3 - obstructive lung disease - COPD
4 - Supporative lung disease - bronchiectasis and CF
Investigations of ILD
Manage the disease and investigate for an underlying cause
Peripheral saturation and ABG to assess for LTOT
Bloods incl RF, ANCA and dsDNA to exclude a connective tissue diagnosis
CXR and HRCT
Spirometry to restrictive pattern
Echo for R heart function
Bronchoscopy +/- biopsy
Contraindication for lung transplant
Current sepsis / infection / AIDS
Disseminated malignancy or within past 5yrs
Significant pyschiatic hx causing inability to comply with immunosuppressive regime
Very high (>35) or low (<17) BMI
Current smoking / drug use
Co-morbidities - Untreatable other organ failure - heart, liver, kidney or atherosclerotic disease not amenable to revascularisation
3 causes of bronchiectasis
Primary / idiopathic
Associated with smoking-related COPD
Post infection (pertussis, measles, TB) Congenital - yellow nail, Kartageners Cystic fibrosis Immunodeficiency - hypogammaglobulinaemia ABPA
Causes of apical lung fibrosis
Beryllium Radiation Extrinsic allergic alveolitis (EAA) ABPA and ank spond Sarcoidosis TB
Complications of lung transplant
1 - surgical complications - recurrence, failure, pain, scarring, bleeding, infection (typical and atypical, viral, bacterial and fungal)
2 - complications related to immunosuppression - infection and malignancy (skin, lymphoproliferative)
3 - rejection - hyper-acute, acute and chronic (bronchiolitis obliterans is usual mode - leading cause of death after first year)
4 - recurrence of disease
5 - SE of drugs - tacrolimus (tremor and raised BM), ciclosporin (renal impairment and gum hypertrophy), mycophenylate (BM suppression), steroids (Cushingoid)
Clinical manifestations of cystic fibrosis
Failure to thrive and meconium ileus
GI: Chronic malnutrition Pancreatic insufficiency Bowel obstruction DM and gallstones
Resp:
Bronchiectasis and abscess formation
Infertility (absence of vas deferens)
Renal stones
