Respiratory: Asthma, COPD & Lung Cancer Flashcards
1
Q
Give some red flags for a respiratory history/examination
A
- Weight loss
- Haemoptysis
- Persistent dry cough (>3 weeks)
- Foreign travel
- Smoking history
- Sudden onset SOB
- Chest pain
- Drenching night sweats
2
Q
What is the most common lung disease in the UK?
A
Asthma
3
Q
Give the 3 mechanisms behind airway narrowing in asthma
A
1) Bronchial muscle contraction
2) Inflammation caused by mast cell degranulation
3) Increased mucus production
4
Q
Asthma often shows a diurnal variation. What does that mean?
A
Symptoms worse in morning
5
Q
percussion in acute asthma?
A
hyperresonant (air)
6
Q
Inflation of lungs in acute asthma?
A
hyperinflation
7
Q
Auscultation of lungs in acute asthma?
A
Bilateral decreased air entry
Wheeze
8
Q
Are symptoms in asthma bilateral or unilateral?
A
Bilateral
9
Q
What is a ‘silent chest’ in asthma a sign of?
A
Severe illness - life-threatening
10
Q
What is the diagnostic investigation in asthma?
A
Spirometry
11
Q
How does spirometry and PEFR differ?
A
Both tests measure the speed and efficiency with which air moves in and out of the lungs.
Spirometry - offers a larger set of parametric values regarding lung health than a peak flow meter does and requires a patient to perform specific breathing manoeuvres using a spirometer.
PEFR - can be performed at bedside/patient home
12
Q
What spirometry result indicates asthma?
A
FEV1/FVC <0.7 (70%) –> obstructive airway disease
13
Q
What is the FEV1/FVC ratio?
A
The FEV1/FVC ratio is the ratio of the forced expiratory volume in the first one second to the forced vital capacity of the lungs (i.e. indicates how much air you can forcefully exhale)
Measured by spirometry
14
Q
Give some other investigations that can be used in chronic asthma?
A
1) Bronchodilator reversibility tests
2) FeNO (fractional exhaled nitric oxide)
3) Skin prick test - confirm atopy
15
Q
What bronchodilator reversibility test result indicates asthma?
A
Improvement of FEV1 >12% after bronchodilator therapy is diagnostic
16
Q
What is the stepwise pharmacological long-term management of asthma (NICE)
A
- SABA
- ICS (low dose)
- LTRA e.g. montelukast
4a) SABA + low dose ICS + LABA (can stop or continue LTRA depending on patient’s response)
5) SABA +/- LTRA, switch ICS/LABA for a MART that includes low dose ICS
6) SABA +/- LTRA + MART (medium dose ICS)
17
Q
What are the aims of pharmacological management of asthma?
A
- No daytime symptoms
- No night-time waking due to asthma
- No asthma attacks
- No limitations on activity including exercise
- Minimal side effects from medication
18
Q
Pathophysiology behind an asthma attack?
A
IgE type 1 hypersensitivity reaction leading to smooth muscle contraction, bronchial oedema and mucus plugging.
19
Q
What medications can exacerbate asthma?
A
1) Acetylcholinesterase inhibitors e.g. Donepezil
2) Beta blockers e.g. bisoprolol
3) NSAIDs
20
Q
Why can AChEIs exacerbate asthma?
A
Due to increased bronchial secretions
21
Q
Give some triggers for an asthma attack
A
- Exposure to allergens e.g. dust, pollution, animal hair or smoke
- URT or LRTIs
- Cessation or reduction of asthma medications
- Concomitant medications e.g. beta blockers, NSAIDs
- Triggers e.g. exercise, cold air
22
Q
Give some signs of an acute asthma attack
A
- Use of accessory muscles of respiration
- Hyperinflation of the chest
- Tachypnoea
- Tachycardia
- Diaphoresis (sweating)
23
Q
Give some signs of a severe asthma attack
A
- Inability to speak in full sentences
- RR >25
- Peak flow 33-50% predicted
24
Q
Give some signs of a life-threatening asthma attack
A
- PEFR <33% predicted
- O2 sats <92%
- Silent chest on auscultation
- Confusion
- Bradycardia
- Hypotension
- Cyanosis
- Exhaustion – weak or no respiratory effort
25
What may bradycardia in a life-threatening asthma attack indicate?
Impending respiratory attack
26
What does an FeNO test indicate?
Measures level of NO in breath which is a sign of inflammation in lungs
27
Which bloods are important in acute asthma?
* FBC – infection
* CRP – infection
* Eosinophil count
* Total IgE
* IgE to aspergillus
28
Which imaging is 1st line in acute asthma?
CXR
29
What may a CXR in acute asthma show?
usually normal (may show hyperinflation or bronchial wall thickening)
30
Give the stepwise pharmacological management in an acute asthma attack (ABCDE)
1. Sit up and give oxygen
2. Nebulised salbutamol (high dose)
3. Corticosteroid (oral prednisolone or IV hydrocortisone)
4. Nebulised ipratropium bromide (if needed)
Maybe:
5. IV magnesium sulphate
6. IV aminophylline
31
When would ipratropium bromide be given in acute asthma? What is the effect of this?
Add for patients with acute severe or **life-threatening asthma or to those with a poor initial response to b2 agonist therapy.
Combining nebulised ipratropium bromide with a nebulised b-2 agonist produces significant bronchodilation than a b-2 agonist alone.
32
Who should steroid therapy be administered to in patients presenting with an acute asthma attack?
ALL patients with acute asthma
33
What steroids should be used in acute asthma?
Oral prednisolone 40-50mg
If oral route unavailable (likely) → IV hydrocortisone
34
How long should oral prednisolone be continued for following an acute asthma attack?
5 days or until full recovery
35
When would you consider giving IV magnesium sulphate in acute asthma?
* Acute severe asthma who have not had a good response to inhaled therapy
* Life-threatening or near-fatal asthma
* Only use after consultation with senior medical staff
36
What would reduced air entry in acute asthma indicate?
significant airway compromise
37
What would absent air entry on auscultation in acute asthma indicate?
Underlying pneumothorax
38
What would dullness on percussion in acute asthma indicate?
- Pleural effusion
- Lobar collapse
39
Typical ABG results in acute asthma?
Low PaO2 and low PaCo2
40
What is COPD?
A triad of chronic bronchitis, emphysema and small airway fibrosis causing irreversible obstruction of air flow; bronchitis or emphysema can be the predominant condition.
41
Most common cause of COPD?
Smoking (95%)
42
Which inherited disorder can predispose to COPD?
Alpha 1 antitrypsin deficiency
43
How is alpha 1 antitrypsin deficiency inherited?
Autosomal dominant
44
How does alpha 1 antitrypsin deficiency increase risk of COPD?
Alpha 1 antitrypsin is a protein produced by the liver that protects the lungs.
Without this, the lungs are more easily damaged e.g. by dust
45
What other conditions can alpha 1 antitrypsin deficiency predispose to?
Liver cancer & lung cancer
46
COPD is usually a combination of chronic bronchitis and emphysema. What are these 2 conditions?
Chronic bronchitis - chronic inflammation of the bronchi (usually defined as a productive cough on most days for 3 months a year over 2 successive years)
Emphysema - enlargement of air spaces in the terminal bronchioles leading to inefficient gas exchange ratios and poor air outflow
47
What is the pathogenesis behind COPD?
Chemicals and heat trigger inflammation in bronchi and lung parenchyma
* Bronchi → persistent inflammation leads to scarring and mucus hyperplasia (bronchitis)
* Parenchyma → inflammation leads to alveolar wall loss (emphysema)
48
Give some triggers for COPD exacerbations
* Viral or bacterial lung infection (acute bronchitis or pneumonia)
* Smoking
* Exposed to smoke or air pollution
49
Give some symptoms of COPD
* Dyspnoea (may only happen at first when exercising)
* Chronic productive cough (sputum usually colourless, may become green in LRTIs)
* Recurrent LRTIs
* Fatigue
* Headache (due to CO2 retention)
* Trouble taking a deep breath
* Chest tightness
50
Give some symptoms of an exacerbation of COPD
* More coughing, wheezing, or SOB than usual
* Changes in colour, thickness or amount of mucus
* Feeling tired for more than 1 day
* Swelling of legs or ankles
* O2 levels lower than normal
* Severe --> cyanosis, severe SOB, chest pain, confusion
51
What signs are seen in a COPD exacerbation?
* Accessory muscle use & pursed lips
* Tachypnoea
* Hyperinflation
* Reduction of cricosternal distance
* Reduced chest expansion
* Hyper resonant percussion
* Decreased/quiet breath sounds
* Wheeze on auscultation (due to inflammatory airway oedema and mucous obstruction)
* Cyanosis
* Cor pulmonale (signs of RHF)
* CO2 retention flap
* Reduced conscious level
* Severe → tachycardia, tachypnoea, hypoxia, cyanosis, reduced consciousness
52
What is the typical spirometry finding in COPD?
FEV1/FVC \<0.7
53
What SpO2 should you aim for in COPD patients?
88-92%
54
How can COPD affect the heart?
COPD can cause low oxygen levels in the blood, thereby placing additional stress on the heart.
This can lead to right ventricle hypertrophy and potentially cor pulmonale
55
What 2 cardiac conditions can COPD lead to?
1. Right ventricle hypertrophy
2. Cor pulmonale
56
What is cor pulonale?
Cor pulmonale is a condition that causes the RIGHT side of the heart to fail.
Long-term high blood pressure in the arteries of the lung and right ventricle of the heart can lead to cor pulmonale
57
Which side of the heart fails in cor pulmonale?
Right
58
What may an FBC show in COPD?
Raised MCV - polycythaemia
59
What is MCV? What does it measure?
Mean corpuscular volume --> MCV blood test measures the average size of your red blood cells.
60
What is polycythaemia?
Increased number of RBCs
61
Cause of polycythaemia in COPD?
compensatory physiologic response to hypoxia.
62
What may an ABG show in COPD?
Low PaO2
Raised PaCO2 (type 2 respiratory failure)
63
What is the purpose of a sputum sample in COPD exacerbation?
Enables targeted antibiotic therapy
64
What may a CXR show in COPD
* Hyperinflated chest (\>6 anterior ribs)
* Bullae
* Decreased peripheral vascular markings
* Flattened hemidiaphragms
65
How should oxygen be delivered to COPD patients during acute exacerbations?
Use a venturi mask and titrate appropriately
Sit them upright.
66
Give the pharmacological management of an acute COPD exacerbation
1. Oxygen
2. Nebulised salbutamol
3. Nebulised ipratropium bromide
4. Steroids
67
What steroids should be used in the management of a COPD exacerbation?
Oral prednisolone (IV hydrocortisone if needed)
68
Give the stepwise pharmacological management of chronic COPD
1. Short acting B2-agonist (SABA) OR short acting muscarinic antagonist (SAMA)
2. Add LABA and LAMA
3. LAMA + LABA + ICS
69
Example of a short acting muscarinic antagonist (SAMA)?
Ipratropium bromide
70
What ECG changes may be seen in COPD?
- Right axis deviation
- Prominent p waves in inferior leads
- Inverted p waves in high lateral leads (I, aVL)
- Low voltage QRS
- P pulmonale
- RBBB
Looks these up
71
What may the presence of tall, peaked P waves in lead II indicate?
A sign of right atrial enlargement, usually due to pulmonary hypertension
72
Where is the apex beat located?
5th intercostal space, mid-clavicular line
73
What are Curschmann spirals? What conditon are they present in?
Can be seen on histology where shed epihetlium becomes whorled mucous plugs
Asthma
74
What % of lung cancers are thought to be preventable?
80%
75
Histologically, what are the 2 types of lung cancer?
1) Small-cell lung cancer (SCLC) (20%)
2) Non-small-cell lung cancer (NSCLC) (80%)
76
Are small cell or non small cell lung cancers more common?
Non-small cell (80%)
77
What is the most common type of NSCLC?
Adenocarcinoma (40%)
78
What is the 2nd most common type of NSCLC?
Squamous cell carcinoma (20%)
79
Give 3 main types of NSCLC
1) Adenocarcinoma (40%)
2) Squamous cell carcinoma (20%)
3) Large cell carcinoma (10%)
4) Other types (around 10%)
80
Give some red flag symptoms for lung cancer
- Cachexia
- Pain when breathing (dyspnoea)
- Haemoptysis
- Persistent dry cough
- N&V
- Chest pain
80
Lung cancer can present with Horner's syndrome. Give the location of the tumour in this instance
Apical tumour (e.g. Pancoast) --> interrupted sympathetic supply to face
81
Which type of cancer is responsible for paraneoplastic syndromes? Why?
SCLC --> contain neurosecretory granules that release neuroendocrine hormones.
82
Which type of lung malignancy is strongly linked to asbestos inhalation?
Mesothelioma
83
What is mesothelioma?
Mesothelioma is a lung malignancy affecting the mesothelial cells of the pleura.
84
What is the latent period of mesothelioma (i.e. exposure to mesothelioma)?
Up to 45 years
85
What is the prognosis of mesothelioma?
Very poor - chemotherapy can improve survival, but it is essentially palliative.
86
What findings may there be in lung cancer in a respiratory exam?
- SOB
- Cough
- Haemoptysis
- Finger clubbing
- Recurrent pneumonia
- Weight loss
- Lymphadenopathy
87
Which lymph nodes tend to be found first on examination in lung cancer?
Supraclavicular nodes
88
Lung cancer can lead to many complications.
What chest signs could be seen during an examination?
- Consolidation: pneumonia
- Collapse: absent breath sounds, ipsilateral tracheal deviation
- Pleural effusion: stony dull percussion, decreased vocal resonance and breath sounds
89
Lung cancer is associated with a lot of extrapulmonary manifestations and paraneoplastic syndromes. These are linked to different types and distributions of lung cancer.
Sometimes they can be the first evidence of lung cancer in an otherwise asymptomatic patient.
xam questions commonly ask you to suggest the underlying cause of a paraneoplastic syndrome.
Give some paraneoplastic syndromes associated with lung cancer?
- Phrenic nerve palsy
- Recurrent laryngeal nerve palsy
- Superior vena cava obstruction
- Horner's syndrome
- Syndrome of inappropriate ADH (SIADH)
- Cushing's syndrome
- Hypercalcaemia
- Limbic encephalitis
- Lambert-Eaton myasthenic syndrome
90
Position of lung tumour causing recurrent laryngeal nerve palsy?
It is caused by a tumour pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum.
91
How does recurrent laryngeal nerve palsy present?
Hoarse voice
92
How does phrenic nerve palsy present?
Causes diaphragm weakness and presents with SOB.
93
What are most cases of SVC obstruction caused by?
Lung cancer
94
How does a lung tumour cause SVCO?
It is caused by direct tumour compression on the superior vena cava.
95
How does SVCO present?
- Facial swelling
- Difficulty breathing
- Distended neck and upper chest veins
This is a medical emergency.
96
What is Pemberton’s sign?
In SVCO --> where raising the hands over the head causes facial congestion and cyanosis.
97
What is Horner's syndrome?
Presentation?
Caused by a tumour in the pulmonary apex (e.g. Pancoast tumour) pressing on the sympathetic ganglion and interrupting
Triad of:
1) ptosis
2) anhidrosis
3) miosis
Also can have enopthalmos.
98
What is Syndrome of inappropriate ADH (SIADH)?
Can be caused by ectopic ADH secreted by a small-cell lung cancer.
It presents with hyponatraemia.
99
How does SIADH present?
Hyponatraemia
100
How does SIADH lead to hyponatraemia?
Excess ADH secretion --> body retaints too much water --> hyponatraemia
101
Presentation of hyponatraemia?
Mild:
- nausea
- malaise
- lethargy
- headaches
Severe:
- decreased level of consciousness
- seizures
- coma
102
How can SCLC lead to Cushing's syndrome?
Ectopic ACTH secretion
103
How can SCLC lead to hypercalcaemia?
Ectopic parathyroid hormone.
PTH increases serum calcium by:
1) PTH releases calcium from bones
2) PTH increases amount of calcium absorbed from small intestine
3) PTH decreases calcium lost in urine
104
Symptoms of hypercalcaemia?
Stones --> renal stones, the need to drink more fluids
Bones --> bone pain, fragile bones that break more easily
Groans --> GI symptoms e.g. N&V, constipation, tummy pain
Moans --> fatigue, confusion, coma
105
What is limbic encephalitis?
Symptoms?
A paraneoplastic syndrome where SCLC causes the immune system to make antibodies to tissues in the brain, specifically the limbic system, causing inflammation in these areas.
- short-term memory impairment
- hallucinations
- confusion
- seizures
106
What antibodies is limbic encephalitis associated with?
anti-Hu antibodies.
107
What is Lambert-Eaton myasthenic syndrome?
Its caused by antibodies against small-cell lung cancer cells.
These antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones.
108
Symptoms of Lambert-Eaton myasthenic syndrome?
- Weakness --> particularly in proximal muscles
- Can affect intraocular muscles --> diplopia
- Can affect levator muscles --> ptosis
- Can affect pharyngeal muscles --> slurred speech and dysphagia
- Autonomic dysfunction --> dry mouth, impotence, dizziness
109
What are the proximal muscles?
Those muscles that are closest to the core of your body, including the upper legs, hips, upper arms, shoulders and the core itself.
110
What muscles does Lambert-Eaton myasthenic syndrome affect?
Weakness in proximal muscles
111
Give the pathology behind lung cancer manifesting as SOB
If cancer invades major airways
Phrenic nerve palsy
112
Give the pathology behind lung cancer manifesting as haemoptysis
Invasion of cancer into airways (friable tissue) may lead to bleeding
113
Give the pathology behind lung cancer manifesting as pain
Local invasion affecting the lining of the pleural cavity or bone, causing pain
114
Give the pathology behind lung cancer manifesting as a pleural effusion
Can cause inflammatory reactions which can leads to the accumulation of fluid in the pleural space
115
Give the pathology behind lung cancer manifesting as a superior vena cava obstruction
Cancer may invade into surrounding lung tissues, leading to compression of the draining of the SVC leading to dyspnoea and facial plethora due to venous congestion
116
Give the pathology behind lung cancer manifesting as a pneumothorax
Invasion of the tumour may lead to a communication between the lung parenchyma and the pleural cavity, resulting in the collapse of the lung
117
Give the pathology behind lung cancer manifesting as atelectasis
Invasion may lead to total obstruction of the airway leading to collapse of that lobe
118
What is the 1st line investigation in suspected lung cancer?
CXR
119
What is referral criteria for suspected cancer (2 week referral for CXR)?
Patients over 40 with:
- Clubbing
- Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes)
- Recurrent or persistent chest infections
- Raised platelet count (thrombocytosis)
- Chest signs of lung cancer
TIP: Remember two key examination findings that automatically indicate an urgent CXR: 1) finger clubbing and 2) supraclavicular lymphadenopathy. These are quick things to check for. Spotting them could lead to an early diagnosis, potentially saving a patient’s life.
NICE also recommend offering a chest x-ray to patients over 40 years old who have:
1) Two or more unexplained symptoms in patients that have never smoked
2) One or more unexplained symptoms in patients that have ever smoked or had asbestos exposure
120
Platelet level in lung cancer?
Raised (thrombocytosis)
121
Unexplained symptoms for lung cancer?
- Cough
- SOB
- Chest pain
- Fatigue
- Weight loss
- Loss of appetite
TIP: It is very common for patients to present with vague symptoms of fatigue or shortness of breath, and your first thought might not be of lung cancer. If a 50 year old ex-smoker presents feeling “tired all the time” with no other symptoms, these guidelines suggest considering an urgent chest x-ray to exclude lung cancer. Equally, someone that has never smoked presenting with weight loss and general fatigue would qualify. This results in a low threshold for an urgent chest x-ray.
122
What CXR findings would suggest lung cancer?
- Hilar enlargement
- Peripheral opacity (a visible lesion in the lung field)
- Pleural effusion
- Collapse
123
Is pleural effusion typically unilateral or bilateral in lung cancer?
Unilateral
124
What investigation is then used to assess the stage, lymph node involvement and presence of metastases in lung cancer?
Staging CT scan of the chest, abdomen and pelvis.
This should be contrast-enhanced, using an injected contrast to give more detailed information about different tissues.
125
What is a PET-CT (positron emission tomography) scan?
Purpose?
Involves injecting a radioactive tracer (usually attached to glucose molecules) and taking images using a combination of a CT scanner and a gamma-ray detector to visualise how metabolically active various tissues are.
They help identify metastases by highlighting areas of increased metabolic activity.
126
What is a bronchoscopy with endobronchial ultrasound (EBUS)?
Purpose in lung cancer?
Involves endoscopy with ultrasound equipment on the end of the scope.
This allows detailed assessment of the tumour and ultrasound-guided biopsy.
127
Histological diagnosis requires a biopsy to check the type of cells in the tumour.
Via what 2 ways can this biopsy be done?
1) Bronchoscopy
2) Percutaneous biopsy (through the skin).
128
What is the most common type of lung cancer in the UK?
Adenocarcinoma
129
Which lung cancer is the least likely to be related to smoking?
Adenocarcinoma
130
What cells do adenocarcinomas arise from?
Arises from mucous cells in bronchial epithelium
131
Which type of lung cancer is most likely to cause a pleural effusion?
Adenocarcinoma (and mesotheliomas)
132
Which type of lung cancer is most commonly related to hypercalcaemia?
Squamous cell carcinoma
133
Lung cancer can cause hypercalaemia via which 2 mechanisms?
1. bone destruction
2. production of PTH analogues
134
What cells do small cell lung cancers arise from?
From endocrine cells (Kulchitsky cells) – these are APUD cells
135
What are Kulchitsky cells?
The bronchial mucosa also contains a small cluster of neuroendocrine cells, also known as Kulchitsky cells
136
Which 2 hormones with SCLCs most typically secrete? Why?
1) Adrenocorticotropic hormone (ACTH)
2) Anti-diuretic hormone (ADH)
137
SCLC is also associated with Addison's disease. What is the pathophysiology behind this?
Tissue destruction of the adrenal glands --> low cortisol (and aldosterone)
138
What is Lambert-Eaton syndrome?
The result of antibodies produced by the immune system against small cell lung cancer cells
139
Why are SCLCs responsible for multiple paraneoplastic syndromes?
SCLCs contain neurosecretory granules that can release neuroendocrine hormones
140
Pathophysiology behind Lambert-Eaton syndrome?
Antibodies target and damage voltage-gated calcium channels in motor neurons
141
Symptoms of Lambert-Eaton?
* Proximal weakness
* Intraocular muscle weakness – diplopia (double vision)
* Levator muscles in eyelid weakness – ptosis
* Pharyngeal muscle weakness – slurred speech, dysphagia
* Reduced tendon flexes
142
1st line management in NSCLC in patients with disease isolated to a single area?
Surgery --> intention is to remove the entire tumour and cure the cancer
143
Management options in NSCLC?
1) Surgery
2) Radiotherapy (can be curative when diagnosed early)
3) Chemotherapy
Chemotherapy (an be offered in addition i.e. adjuvant or as palliative treatment in later stages i.e. palliative chemo
144
Management options in SCLC?
Usually with chemotherapy or radiotherapy
The prognosis is generally worse than NSCLC.
145
How can bronchial obstruction caused by lung cancer be relived as part of palliative treatment?
Endobronchial treatment with stents or debulking can be used to relieve bronchial obstruction caused by lung cancer.
146
Different surgery options for lung cancer?
1) Segmentectomy or wedge resection - removing a segment or wedge of lung (a portion of one lobe)
2) Lobectomy - removing entire lung lobe containing tumour
3) Pneumonectomy - removing entire lung
147
What is the most common surgical option in lung cancer?
Lobectomy
148
What are the 3 main thoracotomy incisions?
1) Anterolateral thoracotomy with an incision around the front and side
2) Axillary thoracotomy with an incision in the axilla (armpit)
3) Posterolateral thoracotomy with an incision around the back and side (the most common approach to the thorax)
149
What respiratory cases might a thoracotomy scar in your OSCEs indicate?
1) lobectomy
2) pneumonectomy
3) lung volume reduction surgery for COPD
150
What does a right-sided mini-thoracotomy incision scar in a cardiology station?
Usually minimally invasive mitral valve surgery
151
What auscultation sounds would indicate a pneumonectomy?
Absent breath sounds on an entire side
152
What auscultation sounds would indicate a lobectomy?
Focal absent breath sounds
153
Previously, what were lobectomies and pneumonectomies used to treat?
TB (remember this in older patients)
154
What is a pneumothorax?
Air in pleural space - separating lung from chest wall
155
What are the 2 major classifications of a pneumothorax?
Spontaneous & 2ary (to trauma, medical interventions i.e. iatrogenic, or lung pathology)
156
Typical patient with a pneumothorax in exams?
A tall, thin, young man presenting with sudden breathlessness and pleuritic chest pain, possibly whilst playing sports.
157
Causes of a pneumothorax?
- Spontaneous
- Trauma
- Iatrogenic, for example, due to lung biopsy, mechanical ventilation or central line insertion
- Lung pathologies such as infection, asthma or COPD
158
Give some underlying pathologies that can lead to 2ary spontaneous pneumothorax's
- Connective tissue disease e.g. Marfan’s syndrome, Ehlers-Danlos syndrome
- Obstructive lung disease e.g. asthma, COPD
- Infective lung disease e.g. TB, pneumonia
- Fibrotic lung disease e.g. cystic fibrosis, idiopathic pulmonary fibrosis
- Neoplastic disease e.g. bronchial carcinoma
159
Traumatic pneumothorax's can be classified into iatrogenic and non-iatrogenic causes.
Give some examples for both
Iatrogenic --> central line insertion, positive pressure ventilation, lung biopsy
Non-iatrogenic --> penetrating trauma, blunt trauma with rib fracture
160
Give some symptoms of a pneumothorax
* Sudden onset SOB
* Pleuritic chest pain
161
How is each factor affected in a pneumothorax:
a) Chest expansion
b) Percussion
c) Breath sounds
d) Vocal resonance
a) reduced on affected side
b) hyperresonant on affected side
c) reduced/absent on affected side with no added sounds
d) reduced on affected side
162
What is the 1st line investigation in a pneumothorax?
CXR
163
How is patient positioned in a CXR for a simple pneumothorax?
Erect (i.e. standing)
164
CXR findings in a pneumothorax?
It shows an area between the lung tissue and the chest wall with no lung markings. There will be a line demarcating the edge of the lung where the lung markings end and the pneumothorax begins.
165
How is a pneumothorax measured in size on a CXR?
Measuring horizontally from the lung edge to the inside of the chest wall at the level of the hilum (see zero to finals).
166
What imaging can be used to detect a pneumothorax that is too small to be seen on a chest x-ray?
CT thorax
167
What imaging can be used to measure the size of a pneumothorax ACCURATELY?
CT thorax
168
Management of pneumothorax that is ess than a 2cm rim of air on the CXR and there is no SOB?
1) No treatment is required as it will spontaneously resolve
2) Follow-up in 2 – 4 weeks is recommended
169
Management of a pneumothorax that is more than a 2cm rim of air on the CXR and there is SOB?
Aspiration followed by reassessment
170
If aspiration fails in a pneumothorax, what is the next step?
Chest drain
N.B. Unstable patients, bilateral or secondary pneumothoraces, generally require a chest drain.
171
What type of cannula is used to aspirate a pneumothorax?
A 16-18G cannula under local anaesthetic
172
Where is a chest drain located in a pneumothorax?
Triangle of safety
173
What is the triangle of safety formed by (3 borders)?
1) 5th intercostal space (or inferior to nipple)
2) Midaxillary line (or lateral edge of latissimus dorsi)
3) Anterior axillary line (or lateral edge of pectoralis major)
See zero to finals for picture
174
Is the needle inserted above or below the rib when inserting a chest drain in a pneumothorax?
The needle is inserted just above the rib to avoid the neurovascular bundle that runs just below the rib.
175
Once the chest drain has been inserted in a pneumothorax, what should you do?
Get a CXR to check positioning
176
How does a chest drain work in treating a pneumothorax?
1) The external end of the drain is placed underwater, creating a seal to prevent air from flowing back through the drain into the chest.
2) Air can exit the chest cavity and bubble through the water, but the water prevents air from re-entering the drain and chest.
3) During normal respiration, the water in the drain will rise and fall due to changes in pressure in the chest (described as “swinging”).
4) When the chest drain successfully treats the pneumothorax, air will bubble through the fluid in the drain bottle.
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How to know when a chest drain has successfully treated a pneumothorax?
1) There will be swinging of the water with respiration
2) On a repeat CXR there will be reinflation of the lung
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If a chest drain does not appear to have successfully treated a pneumothorax, what may be the problem?
1) Blocked or kinked tube
2) Incorrect position in the chest
3) Not correctly connected to the bottle
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What are 2 key complications of chest drains?
1) Air leaks around the drain site (indicated by persistent bubbling of fluid, particularly on coughing)
2) Surgical emphysema (also known as subcutaneous emphysema) is when air collects in the subcutaneous tissue
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What may indicate an air leak in a chest drain?
Persistent bubbling of fluid, particularly on coughing
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What is a surgical/subcutaneous emphysema?
when air collects in the subcutaneous tissue
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When may patients require SURGICAL interventions for a pneumothorax?
1) A chest drain fails to correct the pneumothorax
2) There is a persistent air leak in the drain
3) The pneumothorax reoccurs (recurrent pneumothorax)
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What surgical method is used to correct a pneumothorax?
Video-assisted thoracoscopic surgery (VATS)
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What are the 3 surgical options for pneumothorax?
1) Abrasive pleurodesis (using direct physical irritation of the pleura)
2) Chemical pleurodesis (using chemicals, such as talc powder, to irritate the pleura)
3) Pleurectomy (removal of the pleura)
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What is pleurodesis?
Pleurodesis involves creating an inflammatory reaction in the pleural lining so the pleura STICKS together and the pleural space becomes SEALED.
This prevents further pneumothoraces from developing.
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What are the 3 pharmacological options for smoking cessation?
1) Nicotine replacement therapy (NRT)
2) varenicline
3) bupropion
NICE state that clinicians should not favour one medication over another
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How long should NRT, varenicline or bupropion be prescribed for in smoking cessation?
Until 2 weeks after target stop date
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General smoking cessation advice?
- Medication should be prescribed as part of a commitment to stop smoking on or before a particular date (target stop date)
- prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date.
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In unsuccessful in smoking cessation using NRT, varenicline or bupropion, when should you offer a repeat prescription?
Should NOT offer within 6 months unless special circumstances have intervened
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Can you offer NRT, varenicline or bupropion together in smoking cessation?
NO
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Side effects of nicotine replacement therapy?
- nausea & vomiting
- headaches
- flu-like symptoms
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How should nicotine replacement therapy be given to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past?
NICE recommend offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray)
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What class of drug is varenicline?
a nicotinic receptor partial agonist
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When should varenicline be started?
1 week before patients target date to stop
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How long is recommended course of treatment of varenicline?
12 weeks (but patients should be monitored regularly and treatment only continued if not smoking)
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Most common side effect of varenicline?
Nausea
Can also have headache, insomnia and abnormal dreams.
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In which patients should varenicline be used with CAUTION in?
Patients with a history of depression or self-harm
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Contraindication of varenicline?
Pregnancy and breast feeding
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What class of drug is Bupropion?
a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
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When should bupropion be started?
1 to 2 weeks before the patients target date to stop
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Contraindications of bupropion?
- Epilepsy (small risk of seizures)
- Pregnancy and breast feeding
- Eating disorder (relative contraindication)
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What is the most common cause of occupational asthma?
Isocyanates e.g. factories producing spray painting, foam moulding using adhesives
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What pCO2 indicates near-fatal asthma?
Raised >6.0 kPa
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What electrolyte abnormality is seen in sarcoidosis?
Hypercalcaemia
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