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Respiratory Flashcards

1
Q

Indications for VATs

A

Lobectomy (could have normal chest examination if old) or wedge resection
Decortication
Bullectomy or pleurectomy (for recurrent pneumothorax)
Lung biopsy

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2
Q

Scars seen in VATs

A

3 scars - larger 3-6cm on lateral chest wall and 2 smaller for instruments in triangle
Sometimes only 2 or 1 scar

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3
Q

Types of lung cancer

A 
Small cell (SIADH, ectopic ACTH, lambert eaton)
Non small cell - usually adenocarcinoma (peripheral, non smokers), squamous cell carcinoma (central, smoking, hypercalcaemia due to ectopic ACTH), large cell, neuroendocrine, broncheoalveolar
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4
Q

Investigation of lung cancer

A

Full history and obs
Bloods - fbc CRP (anaemia, infection), LFT (mets), kidney (treatment, hyponatraemia - SIADH SCLC), clotting (intervention), hypercalcaemia (bony mets or paraneoplastic)
Sputum analysis
CXR
Staging CTCAP, PET CT for SCLC if radically treatable
Tissue diagnosis - bronchoscopy or endobronchial US, percutaneous via radiologist, mediastinoscopy, or biopsy/FNA LN or pleural effusion aspirate
Work up for treatment - spirometry, lung function with transfer factor, walk test or cardiopulmonary exercise test, echo

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5
Q

Treatment of lung cancer

A

Depends on cancer stage and histology in conjunction with patient wishes and co-morbidities/performance status. MDT approach.

SCL- usually disseminated by diagnosis so often aren’t amenable to surgery. Chemo and radiotherapy.
NSC - depending on location/stage, often treated with surgery or radical radiotherapy. If more advanced, chemotherapy/radiotherapy may be needed

Supportive - stop smoking
Medical - chemo
Surgical - lobectomy, pneumonectomy

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6
Q

Bilateral scars ?apical

A

Bilateral pleurectomy for recurrent pneumothoraces
Bilateral bullectomy/lung reduction surgery in COPD
….
?tb treatment in older pt

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7
Q

Treatment for COPD

A

Stop smoking
Pulmonary rehab

SABA -salbutamol
LABA - salmeterol
SAMA - ipratropium
LAMA -tiotoprium

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8
Q

Lobectomy/pneumonectomy indications

A

Smoking related disease
Lung cancer resection - likely early non small cell lung cancer (squamous cell in smoker, adenocarcinoma in non smokers). Needs FEV1 >1.
Malignant nodules
Lung abscess (lobectomy or wedge resection)
Localised bronchiectasis (lobectomy or wedge resection)
TB historically
Lung trauma with significant damage

Pneumonectomy over lobectomy if pathology in upper and lower lobes

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9
Q

Primary vs secondary spontaneous pneumothora

A

Primary - otherwise healthy person

Secondary - underlying lung disease

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10
Q

Initial management of pneumothorax

A

ABCD, senior help

Primary - aspirate up to 2.5L, can be discharged if symptom relief and residual <2cm, if not then chest drain needed

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11
Q

Suction in pneumothorax

A

Rarely used due to risk of re-expansion pulmonary oedema

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12
Q

VATs vs open thoracotomy

A

VATs - less invasive, lower risk of ongoing pain, wound infection and associated with earlier hospital discharge.
But risk of recurrent pneumothorax (worse than thoracotomy) 5% vs 1%

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13
Q

Management of recurring pneuomothorax

A

If recurrent or persistent air leak..
Pleurectomy or pleurodesis
Bullectomy if bullae or blebs

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14
Q

Differentials of polyphonic wheeze

A

Asthma
COPD
Pulmonary oedema

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15
Q

Investigations in asthma

A

Full history
Obs - sats
Bedside - PEFR (diary and diurnal variation - poor control, reduction in early morning), spirometry
Bloods - fbc, ues, crp, ABG in acute setting (?infection, eosinophils), IgE
Triggers - skin prick tests for allergens, RAST bloods
Imaging - CXR

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16
Q

Spirometry in asthma vs COPD

A

Both obstructive - reduced FEV1, preserved FVC and reduced ratio
Asthma - reversible obstruction, improvement following bronchodilator, 200mls FEV1 or 15% improvement in comparison to baseline. Can be normal in well controlled asthma.
COPD - fixed airflow obstruction

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17
Q

Asthma treatment

A 
Stepwise approach
SABA
ICS
Combined ICS + LABA
Montelukast
Oral steroids, refer to respiratory specialists
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18
Q

Causes of airflow obstruction

A

Asthma
COPD
Bronchiectasis
Obliterative bronchiolitis (fixed airflow obstruction, viral, pollutants, GvsH reaction particularly in lung transplant)
Obstructing mass (luminal, extraluminal, foreign body) - likely monophonic wheeze

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19
Q

Presenting interstitial lung disease

A

Find bibasal/apical end expiratory crackles

Other signs: finger clubbing (IPF), dyspnoea, oxygen, AF/PPM (?amiodarone)

Comment on signs of connective tissue disease (R.A, S.S, SLE)

Most likely cause - ?IPF

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20
Q

Causes of bibasal creps

A

Interstitial lung disease - fine
Bronchiectasis - coarse
Bilateral pneumonia
Congestive heart failure - peripheral oedema, JVP

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21
Q

Investigations in interstitial lung disease

A
  • Full history
  • Obs - sats
  • Bloods - fbc (anaemia, infection), renal and liver function (for starting meds), ?CTD (AI screen i.e. RF, dsDNA, ANA, ANCA), ABG (?LTOT), allergy testing (avian precipitins in bird fanciers lung)
  • Imaging - CXR, high resolution CT (honey combing = fibrosis, ground glass = alveolitis, fibrosis), echo (pulmonary hypertension), spirometry (normal or restrictive. reduced FEV1 and FVC, preserved ratio, reduced TLC and transfer factor)
  • Bronchoscopy with BAL
  • Transbronchial or surgical lung biopsy
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22
Q

Treatment of ILD

A

MDT - PT/OT, respiratory and oxygen nurses to improve QoL, rheumatologist (?CTD), physicians, surgeons
Pulmonary rehab
DMARD for CTD
Steroids/immunosuppressive therapy if ground glass/non specific interstitial pneumonia
If IPF - antifibrotic agent (perfenidone and nintedanib)
FVC 50-80% predicted referral to specialist centre for antifibrotics
Referral for lung transplant if no CI

Tertiary centre - MDT to review investigations i.e. HRCT so try to ascertain underlying aetiology

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23
Q

Causes of ILD

A

Diffuse parenchymal lung disease

Apical = inhalation - TRASHE - TB, Radiation, Ankspond/ABPA, Sarcoidosis, Histoplasmosis, Extrinsic allergic alveolitis

Basal - CAUD - CTD, Asbestosis, UIP (IPF), Drug induced

Idiopathic - IPF (>45, clubbing), sarcoidosis, COP
Allergies - EAA i.e. bird fanciers lung
Occupational - asbestosis, silicosis
CTD - RA, SLE, dermatomyositis, S.S, polymyositis, MCTD
Drugs - amiodarone, nitrofurantoin, methorexate, chemotherapy

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24
Q

Prognosis in IPF

A

Median survival 2 yrs from diagnosis
Poor prognostic factors - older age, dyspnoea, low or declining pulmonary function, emphysema, low ET, exertional desaturation

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25
Treatment of non specific interstitial pneumonia
Immunosuppressive treatment in mod-severe disease Steroids and steroid sparing (MM, aza) Prognosis - better than IPF, 5 yr mortality 15-25%
26
Presenting CF
Bronchiectasis - coarse crackles classically upper lobe, changes on coughing Extra signs - clubbing, oxygen, gastrostomy tubes, portacath sites, low BMI
27
Cause of CF
Multi system disease AR condition transmitted by CFTR gene Leads to increased salt excretion - thicker mucus affecting resp system, digestive tracts leading to pancreatitc insufficneciy and reproductive tracts
28
Manifestations of CF
Resp - bronchiectasis, infections (each patient ahs different flora colonised, can get pseudomonas aeruginosa commonoly, mycobacterium and burkholderia cepacia is poor prognosis), pneumothorax, haemoptysis, APA GIT - pancreatic insufficiency, need fat sol vitamins and creon, liver disease (HSP), gall stones, diabetes, constipation and obstruction GU - kidney stones GUM - reproductive difficulties (classically in men) Sinus disease, nasal polyps
29
Treatment of CF
MDT in specialist centre - dietician, dr, social worker, physio, endocrinologist Resp - physiotherapy for positional drainage or enhanced breathing techniques and exercise to clear mucus, nebulised therapy of mucolytics (hypertonic saline) and prophylactic abx, regular azithromycin, IV abx GIT - creon, dietician input, fat soluble vits, nutritional supplements via PEG, insulin therapy
30
Lung transplant in CF
Burkholderia and mycobacterium - absolute CI
31
Diagnosis of CF
Infant screening - heel prick Guthrie test Screening for commonest CFTR mutations on blood test Sweat test
32
Lung transplant presentation
Single (lateral thoracotomy and/or median sternotomy) vs double (clamshell) Drain sites or tracheostomy Transplant working? Cyanosis, oxygen Immunosuppressive side effects (tacrolimus, mycophenolate, steroids, azathioprine) Underlying aetiology - clubbing (?bronchiectasis, CF, IPF)
33
Indications for lung transplant
Chronic end stage lung disease Criteria: >50% die from lung disease within 2 yrs, >80% likelihood surviving 90 days, >80% likelihood survival 5yr post transplant CF (FEV1<30%, significant pulmonary htn, poor ET, high exacerbation freq, NIV) or bronchiectasis Pulmonary vascular disease Pulmonary fibrosis/ILD COPD (single) - 40% transplant, improves QoL not extends, BODE index score >7 best survival
34
Double vs single lung transplant
``` Better prognosis (6yrs generally, 4.5 yrs single, 7.5 double) CF/bronchiectasis or any once risk Vs benefits assessed - double COPD/ILD - single ```
35
S.E lung transplant
Acute - hyperacute rejection, opportunistic infections (bacteria, myco, funga, viral) Chronic - bronchiolitis obliterans syndrome (terminal event, leading cause of death after 1yr) causing chronic rejection, malignancy (post transplant lymphoproliferative disease, skin) Immunosuppressant effects - cushingoid, reduced bone density, diabetes (steroids), diabetes and tremor (tacrolimus), hearing impairment (aminoglycosides and immunosuppressants)
36
Contraindications for lung transplant
Malignancy within last 5 yrs or 2 yrs if low recurrence risk Untreatable significant heart, liver, kidney, brain dysfunction unless combined transplant Atherosclerosis with end organ dysfunction and/or CAD not amenable to revasc Acute illness - sepsis, MI, hepatic failure Chronic infection with highly virulent organisms Raised BMI >35 Smoking or illicit drugs Non adherance to therapies Significant psychiatric history with inability to cooperate with meds/follow up Relative - age >65yrs (single) or >60yrs (double), BMI >30, severe malnutrition, severe osteoporosis, colonised organisms (burkholderia)
37
Presenting bronchiectasis
This patient has bronchiectasis likely caused by ... (yellow nail syndrome, CF, infection) Coarse inspiratory crackles at ..... Productive cough. Clubbing/nail changes. Evidence of long term venous access. Sputum pot at bedside. Associated conditions - yellow nail changes/lymphoedema/pleural effusions (yellow nail syndrome), joint swelling (RA), young (PCD/CF), abdo scars/stoma (IBD)
38
Investigating bronchiectasis
Bloods - fbc, ues, crp, hiv, Ig, pneumococcal serology, aspergillous serology, CF testing <40yrs, AI screen if suggestion of CTD Nasal biopsy if ?PCD Sputum analysis - culture, fungal, mycobacterium Lung function tests and spirometry CXR (can look normal in early disease), HRCT
39
Management of bronchiectasis
MDT - PT, OT, dietician, physicians PT - postural chest drainage and active cycle of breathing techniques, positive expiratory pressure devices. Vaccines - pneumococcal and influenza Mucolytic drugs (carbocisteine) or nebulisers such as hypertonic saline Prophylactic antibiotics i.e. azithromycin Acute infections - 2 week course abx guided by sputum cultures, nebulised abx (colistin) Surgical - localised bronchiectasis with frequent exacerbations on max therapy
40
Causes of bronchiectasis
``` Idiopathic Immunodeficiency CTD - RA Inflammatory - IBD Infection - pneumonia, TB Fungal moulds - ABPA CF ```
41
Clinical history of bronchiectasis
Chest symptoms - chest pain, breathlessness, cough, sputum character and amount, number of infections per year (?courses of abx), wheeze, haemoptysis, previous severe pneumonia, mould exposure (inc gardening) Cause - infertility, sinus problems (CF, primary ciliary dyskinesia), GI symptoms, joint pain, foreign travel
42
Presenting lung cancer
Radiotherapy tattoo Clubbing, hypertrophic pulmonary osteoarthropathy, wasting small muscles of hand Hoarse voice - recurrent laryngeal nerve palsy Horners - ptosis, miosis and anhidrosis (apical pancoasts tumour) SVC obstruction - facial swelling and distended neck veins Cachexia Tar staining Lobectomy/thoracotomy/VATs scar, IC drain Reduced expansion/dull percussion on side of tumour - particularly if lung collapse or previous surgery Palpable LN, monophonic wheeze from tumour, crackles, reduced AE
43
Symptoms and signs of lung cancer
Cough (haemoptysis), breathlessness, weight loss, change in voice character, SVC obstruction (facial or arm swelling, distended veins) Complications of malignancy - hypercalcaemia (thirst, bony pain, confusion)
44
Presenting pleural effusion
Reduced air entry at L/R base, dull to percussion, vocal/tactile fremitus reduced, trachea deviated away from side of effusion Cause - unilateral vs bilateral. Unilateral/exudative: parapneumonic, lung infarction, CTD (sarcoid and RA), malignancy, TB, vasculitis, lymphoma Bilateral/transudative: cardiac failure, liver failure, CKD, hypoalbuminaemia, peritoneal dialysis
45
Transudate vs exudative effusion
Light's criteria - transudate <25g/L, exudate >35g/L. If between: - pleural protein/serum protein = >0.5 - pleural LDH/serum LDH = >0.6 - pleural LDH >2/3rd upper limit normal serum LDH
46
Investigating pleural effusion
US guided aspirate - protein, LDH, pH, culture, cytology (60% malignancies show malignant cells), gram stain, AFB, glucose (low in infection, malignancy, oesophageal rupture, <1.6mmol/L RA)/TG/amylase (higher in pleural fluid than blood), cell count Paired bloods CXR CT + contrast, pleural biopsy via thoracoscopy
47
Treatment of effusion
Guided by underlying cause In parapneumonic: pH <7.2/positive culture/frank pus: drainage In malignancy: if symptomatic or very large = drainage, if recurrent may need indwelling drain, pleurodesis (medically or thoracosopy)
48
Presenting lobectomy
Scar - lateral thoracotomy, drain scar | Deviated trachea
49
Lobectomy vs pneumonectomy signs
Early lobectomy - tracheal deviation towards, reduced breath sounds. Later lobectomy - lung hyper-expansion Pneumonectomy - tracheal deviation towards, reduced chest expansion, dull to percussion and absent breath sounds
50
Prior to pneumonectomy
Needs FEV1 > 2 | Cardiopulmonary exercise testing 15ml/kg/min
51
Differentials for lateral thoracotomy
``` Bullectomy Upper or lower lobectomy, multi-lobectomy Lung biopsy Pleurectomy Previous trauma Wedge resection Pneumonectomy ```
52
Presenting pneumonectomy
Lateral thoracotomy scar Displaced apex beat or tracheal deviation - more likely pneumonectomy Reduced chest expansion, dull on percussion, absent breath sounds (bronchial breathing in upper parts), can have bowel sounds in lower part of chest Causes - cancer? nicotine staining, cachexia, crepitations on remaining lung
53
What to look for post lobectomy/pneumonectomy
Recurrence of disease - cough (haemoptysis), weight loss, cachexia, anaemia, LNs, clubbing, signs in remaining lung Other lung functioning well? - COPD - check smoking cessation
54
Pre surgery - how to assess fitness
Performance status Co-morbidities Lung function tests - lobectomy FEV1>1.5, pneumonectomy FEV1>2 Echo
55
Left anterior chest wall scar
Left anterior mediastinotomy i.e. Chamberlain procedure Surgeon can access area lateral to aortic arch with may contain LN Or used to biopsy masses in mediastinal area
56
Mediastinoscopy scar
Above sternal notch Sample mediastinal nodes Now less common due to endobronchial USS
57
COPD presentation
SOB, oxygen, blue lips/pursed lip beathing Traceal tug, cricosternal distance <3 finger, intercostal indrawing Tremor from salbutamol, nicotine staining Creps and wheeze
58
Spirometry in COPD
``` Obstructive - FEV1/FVC ratio reduced <70% Mild - FEV1 >80% pred Mod - 50-80% Severe - 30-50 V severe <30 ```
59
Treatment of COPD
SABA LABA + ICS LAMA SAMA
60
Cor pulmonale
Right heart failure due to respiratory disease Chronic hypoxia -> pulm vasc vasoconstriction -> pulm htn JVP, right ventricular heave, chest drain scars, VATS, lateral thoracotomy for bullectomy/transplant LTOT (>16 hrs a day) to improve vasoconstriction Diuretics

PACES MRCP (6 decks)

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