Respiratory Flashcards
Indications for VATs
Lobectomy (could have normal chest examination if old) or wedge resection
Decortication
Bullectomy or pleurectomy (for recurrent pneumothorax)
Lung biopsy
Scars seen in VATs
3 scars - larger 3-6cm on lateral chest wall and 2 smaller for instruments in triangle
Sometimes only 2 or 1 scar
Types of lung cancer
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
Investigation of lung cancer
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
Treatment of lung cancer
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
Bilateral scars ?apical
Bilateral pleurectomy for recurrent pneumothoraces
Bilateral bullectomy/lung reduction surgery in COPD
….
?tb treatment in older pt
Treatment for COPD
Stop smoking
Pulmonary rehab
SABA -salbutamol
LABA - salmeterol
SAMA - ipratropium
LAMA -tiotoprium
Lobectomy/pneumonectomy indications
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
Primary vs secondary spontaneous pneumothora
Primary - otherwise healthy person
Secondary - underlying lung disease
Initial management of pneumothorax
ABCD, senior help
Primary - aspirate up to 2.5L, can be discharged if symptom relief and residual <2cm, if not then chest drain needed
Suction in pneumothorax
Rarely used due to risk of re-expansion pulmonary oedema
VATs vs open thoracotomy
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%
Management of recurring pneuomothorax
If recurrent or persistent air leak..
Pleurectomy or pleurodesis
Bullectomy if bullae or blebs
Differentials of polyphonic wheeze
Asthma
COPD
Pulmonary oedema
Investigations in asthma
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
Spirometry in asthma vs COPD
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
Asthma treatment
Stepwise approach SABA ICS Combined ICS + LABA Montelukast Oral steroids, refer to respiratory specialists
Causes of airflow obstruction
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
Presenting interstitial lung disease
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
Causes of bibasal creps
Interstitial lung disease - fine
Bronchiectasis - coarse
Bilateral pneumonia
Congestive heart failure - peripheral oedema, JVP
Investigations in interstitial lung disease
- 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
Treatment of ILD
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
Causes of ILD
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
Prognosis in IPF
Median survival 2 yrs from diagnosis
Poor prognostic factors - older age, dyspnoea, low or declining pulmonary function, emphysema, low ET, exertional desaturation
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%
Presenting CF
Bronchiectasis - coarse crackles classically upper lobe, changes on coughing
Extra signs - clubbing, oxygen, gastrostomy tubes, portacath sites, low BMI
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
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
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
Lung transplant in CF
Burkholderia and mycobacterium - absolute CI
Diagnosis of CF
Infant screening - heel prick Guthrie test
Screening for commonest CFTR mutations on blood test
Sweat test
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)
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
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
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)
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)
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)
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
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
Causes of bronchiectasis
Idiopathic Immunodeficiency CTD - RA Inflammatory - IBD Infection - pneumonia, TB Fungal moulds - ABPA CF
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
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
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)
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
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
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
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)
Presenting lobectomy
Scar - lateral thoracotomy, drain scar
Deviated trachea
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
Prior to pneumonectomy
Needs FEV1 > 2
Cardiopulmonary exercise testing 15ml/kg/min
Differentials for lateral thoracotomy
Bullectomy Upper or lower lobectomy, multi-lobectomy Lung biopsy Pleurectomy Previous trauma Wedge resection Pneumonectomy
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
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
Pre surgery - how to assess fitness
Performance status
Co-morbidities
Lung function tests - lobectomy FEV1>1.5, pneumonectomy FEV1>2
Echo
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
Mediastinoscopy scar
Above sternal notch
Sample mediastinal nodes
Now less common due to endobronchial USS
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
Spirometry in COPD
Obstructive - FEV1/FVC ratio reduced <70% Mild - FEV1 >80% pred Mod - 50-80% Severe - 30-50 V severe <30
Treatment of COPD
SABA
LABA + ICS
LAMA
SAMA
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
