Respiratory Flashcards
Outline the MRC dyspnoea scale
1) Not troubled by SoB (except on strenous exercise)
2) SoB when hurrying or going up slight hill
3) Walks slower than contempories on flat/has to stop for breath
4) Stops for breath approx 100m or after a few minutes
5) Too SoB to leave house or SoB on dressing
Respiratory Causes of Clubbing
ABCDEF
A - Asbestosis & Abscess
B - Bronchiectasis & tB
C - CF
D - “Dirty” tumours e.g. mesothelioma
E - Empyema
F - Fibrosing Alveolitis (IPF)
Features of Life-Threatening Asthma
PEFR<33%
Silent chest
Poor respiratory effort
Bradycardia, hypotension
Arrhythmia
Exhaustion
Confusion/Coma
What is COPD?
Chronic obstructive airways disease
Limited reversibility
Combination of bronchitis and emphysema
Abnormal inflammatory response in airways leads to mucus hypersecretion and chronic tissue destruction –> remodelling –> fibrosis –> increased airway resistance
Commonest cause = cigarette smoking
Also consider alpha 1 antitrypsin deficiency and occupation (e.g. coal mining)
Clinical Features of COPD
Look around bedside for inhalers
?LTOT
Cachexic? Cushingoid appearance?
Pursed lip breathing
Use of accessory muscles
Bounding pulse
CO retention flap (asterixis)
Hyperinflated chest
Hyperresonance to percussion
Expiratory wheeze
?coarse crepitations
Can you name any severity indexes used for COPD?
MRC dyspnoea scale
Gold Staging for Airflow obstruction
- FEV1/FVC < 0.7, FEV1 <80%
BODE index
- FEV1
- 6 minute walk distance
- BMI
- MRC dyspnoea scale
How would you investigate someone in whom you suspect they have COPD?
Spirometry with reversibility testing
- FEV1/FVC < 0.7
- FEV1 < 0.8
- Minimal reversibility with bronchodilators
ECG
Bloods
- Routine including FBC (?polycythaemia), inflammatory markers, U&Es, LFTs (albumin may be low in chronic disease)
- ABG if ongoing oxygen requirement
- alpha1AT levels if young/FHx/minimal smoking history
CXR
- ?hyperinflation ?bullae ?flattened hemidiaphragm
HRCT
- Useful to grade and classify emphysema
Echocardiogram
- ?pulm HTN
Describe some key differences between COPD and Asthma
1) COPD more likely in smokers/ex-smokers
2) Asthma = diurnal pattern
- Serial peak flow measurements will show >20% diurnal variation
3) Asthma = history of triggers, history of atopy
4) Asthma = evidence of reversibility on spirometry with bronchodilators (>400mL improvement)
What are common causes of COPD exacerbations?
Infection (60%)
- Viruses e.g. influenza, parainfluenza, rhinovirus
- Bacteria e.g. haemophilus influenzae, streptococcus pneumoniae, pseudomonas
Environmental pollution
Unknown (30%)
Outline the management of COPD
O PARISIAN
Oxygen therapy
- To slow rate of progression to cor pulmonale
Pulmonary Rehab
= MDT programme of physio, nutrition team, education and behavioural intervention
- Indicated if MRC<3
Azithromycin
- Anti-inflammatory rather than long term antibiotic
- Reduce rate of exacerbations
- Indicated if >3 exacs requiring steroids or 1 exac requiring hospitalisation / year
Reduction of Lung volume (surgery)
Inhalers
- SABA/LABA +/- ICS +/- LAMA
Smoking Cessation
- Only treatment shown to alter disease progression
Immunisations
- Annual influenzae
- Pneumococcal if <65 or FEV1<40%
Anti-mucolytics e.g. Acetylcisteine
- Reduce risk of chest infections
Nutrition
- Poor nutritional state is linked to increased mortality and reduced immune function
When is Long Term Oxygen Therapy indicated in patients with COPD?
PaO2 < 7.3
or
PaO2 <8.0 if polycythaemic/nocturnal hypoxia/cor pulmonale or pulm HTN
Typically use >15 hours/day
Can also consider ambulatory or short burst O2 therapy
Home assessment before prescription
No smoking!
Indications for Lung Transplant in patients with COPD
BODE index >5
Post bronchodilator FEV1 <25%
Resting hypoxia and hypercapnia
Pulmonary HTN
Accelerated decline in FEV1
Can you outline medications we can offer to help with smoking cessation?
1) Nicotine Replacement Therapy
- Assess no. cigarettes/day to help with dosing
- When is their first cigarette? If on waking consider 24 hour patch as opposed to 16 hour
- Patches (long acting) +/- gum +/- inhalator
- Combination of long acting and short acting best
2) Buproprion
- Antidepressant and nicotinic antagonist
- Contraindicated in breastfeeding/pregnancy
- Risk of seizures
3) Varenicline
- Nicotine receptor agonist
- 12 week course
- Nausea/insomnia/abnormal dreams/neuropsychological effects
Indications for NIV
COPD Resp acidosis after 1 hour maximal therapy
= pH <7.35, pCO2 >6
Severe dyspnoea with resp muscle fatigue
T2RF secondary to chest wall deformity/neuromuscular disease/OSA
Cardiogenic pulmonary oedema unresponsive to CPAP
Weaning from tracheal intubation
Benefits of NIV
Bi-level positive airway pressure
- IPAP aids ventilation = removal of CO2
- EPAP recruits collapsed alveoli = improves gas exchange = improves oxygenation
Reduces needs for invasive intubation
(reduce risk of ventilator complications)
Reduce mortality
Reduce length of stay in hospital
Contraindications for NIV
Severe hypoxia (?consider if intubation and ventilation more appropriate)
Undrained pneumothorax
Facial injury
Burns
Fixed upper airway obstruction
Excessive secretions/vomiting
Reduced GCS/agitation
Indications for CPAP
Continuous positive airway pressure (PEEP, basically EPAP)
T1RF
Cardiogenic pulmonary oedema
Congestive cardiac failure
Pneumonia
Sleep apnoea
Outline common causes of Community Acquired Pneumonia
Strep pneumoniae (most common)
Haemophilus influenzae
Mycoplasma pneumoniae
Legionella
Staph Aureus (post influenza)
What is CURB scoring?
C - confusion
U - Urea>7
R - RR > 30
B - BP systolic <90
>65
<2 points, consider treating in community
CURB score of 5 has 57% 30 day mortality
CURB score of 3 has 17% 30 day mortality
What is Bronchiectasis?
Abnormal permanent dilatation and destruction of bronchi due to combination of
1) Chronic infection
2) Impaired mucus drainage
3) Airway obstruction
4) Defective host response
Occurs in distal bronchioles (no cartilage rings)
Causes of Bronchiectasis
CONGENITAL
- Cystic fibrosis (autosomal recessive)
- Kartagener’s (autosomal recessive)
- Young’s syndrome
- Yellow Nail syndrome
COPD
INFECTION
- Childhood infections e.g. measles, pertussis, TB
- Recurrent aspiration
OVERACTIVE IMMUNITY
- ABPA
UNDERACTIVE IMMUNITY
- HIV
- Leukaemia
Outline some complications of Bronchiectasis
Recurrent infections e.g. pseudomonas aeruginosa, haem influenzae
Empyema/abscess
Haemoptysis (can be MASSIVE!)
Cor Pulmonale
Cachexia
Anaemia of chronic disease
Metastatic infection e.g. CNS abscess
Secondary amyloidosis
Investigation Screen for Bronchiectasis
Sputum MC&S and AFB (multiple samples)
Spirometry - usually obstructive picture
Bloods
- Routine = FBC, U&Es, LFTs, inflam markers
- HIV
- Immunoglobulins
- Interferon gamma release assay if suspicious of TB
- Autoantibodies (vasculitis screen)
- Alpha 1 AT levels
- Aspergillus precipitans & IgE levels
CXR
HRCT is definitive test
- “Reid Classification” e.g. signet ring, tree-in-bud, tram-tracking
?Bronchoscopy
EXTRAS
- Sweat testing/genotyping if ?CF
- Nasal brushings if ?Kartagener’s
Outline the management of Bronchiectasis
Treat underlying pathology
CONSERVATIVE
- Stop smoking
- Optimise nutrition
- Vaccinations
- Sputum clearance/chest physio
MEDICAL Rx
- Antibiotics for infective exacerbations (10-14 days)
- Prophylactic azithromycin (antiinflam)
- Inhaled bronchodilators
- Inhaled steroids
- Mucolytics
SURGICAL Rx
- ?Lobectomy if localised
- Lung transplant in CF patients
Cystic Fibrosis
Autosomal recessive disease
Defect in CFTR gene on chromosome 7
- Most common defect = deltaF508
- Carrier rate = 1 in25
Defect in CFTR = chloride ions cannot leave cells = sodium and water reabsorption from mucus back into cells = thick viscous secretions
Multisystem disorder
- Nasal polyps
- Bronchiectasis and recurrent chest infections
- Diabetes (30% by age of 50)
- Malabsorption/FTT
- Biliary cirrhosis –> CLD (30%)
- Delayed puberty
- Infertility
Most diagnosed in neonatal period but 5% diagnosed after age of 18
Examples of common colonising organisms in CF
Haemophilus influenzae (early childhood)
Staph Aureus
Pseudomonas
Aspergillus
Burkholderia Cepacia = worst prognosis!
- Contraindication to lung transplant
Outline the management of CF
MDT Approach
CONSERVATIVE
- Daily chest physio and postural drainage
- Optimise nutrition
- Minimise contact with other CF pts (avoid cross infection)
- Vitamin supplements
- Pancreatic supplements
PHARMACOLOGICAL
- Treatment of pseudomonas colonisations with PO and nebulised antibiotics
- Lumacaftor / Ivacaftor
= indicated if homozygous delta F508 mutation. Increases number of CFTR proteins
SURGICAL
- Heart and lung transplant (5yr survival 60%)
Median survival 32 years but is improving
What is Young’s Syndrome?
Rare condition, unknown cause
Triad of
1) Azoospermia
2) Bronchiectasis
3) Rhinosinusitis
Often present in middle age with infertility
What is Yellow Nail Syndrome?
Rare condition, unknown cause
Usually affects >50s
2 of the 3:
1) Slow growing hard yellow finger and toe nails
2) Lymphoedema
3) Recurrent Pleural effusions + bronchiectasis
What is TB?
Infection caused by mycobacterium tuberculosis
Notifiable disease
Risk Factors for Active Pulmonary TB infection
Place of birth (Sub Sahara Africa & Asia)
Increasing age
HIV/AIDs
Homelessness/Overcrowded living spaces e.g prisons
Immunosuppression e.g. diabetes, chemo
Malignancy
Malnutrition
Outline some examples of extra pulmonary TB
TB meningitis
CNS tuberculoma
Scrofuloderma (cervical LNs)
Pericardial TB
Pott’s disease = spinal osteomyelitis
Spinal TB
Renal TB
Miliary TB = haematogenous spread to any organ
How would you investigate a patient in whom you suspect TB?
Sputum samples x 3 for Ziehl Neelsen staining
Early morning urine samples for AFB x 3
Tuberculin skin resting (Mantoux)
- Can be false negative if immunosuppressed
Interferon gamma Release Assay (Quantiferon)
HIV
CXR
CT Chest
?Bronchoscopy
?Biopsy of extrapulmonary site e.g. LNs
Outline the management of TB
Notifiable disease! Inform public health - contract tracing
May need to have directly observed treatment if no fixed abode/non-compliant
RIPE medications
- Prior to starting, check LFTs and visual acuity/colour
- Typical course is 6 months of R & I, 2 months of P &E
RIFAMPICIN
- Enzyme inducer, red urine, GI disturbance
ISONIAZID
- Hepatitis, peripheral neuropathy
PYRAZINAMIDE
- Hepatoxicity, peripheral neuropathy, gout
ETHAMBUTOL
- Optic neuritis
Potential Clinical Features of a patient with TB previously treated with surgical intervention e.g. plombage, phrenic nerve crush
Tracheal deviation towards side of previous TB
Phrenic nerve crush scar in supraclavicular fossa
Chest deformity/asymmetry
Thoracotomy/thoracoplasty (rib resection) scar
Reduced chest expansion on TB side
Dullness to percussion
Possible respiratory complications of TB
Apical fibrosis
Aspergilloma in old TB cavity
Bronchiectasis secondary to LN obstruction
Pleural effusion/thickening
Causes of Upper Zone Pulmonary Fibrosis
CHARTS
Coal Worker’s pneumoconioses
Histoplasmosis
Hypersensitivity pneumonitis
Histiocytosis X
Ankylosing spondylitis
ABPA
Radiation
TB
Sarcoidosis
Silicosis
Causes of Lower Zone pulmonary fibrosis
RADIO
Rheumatoid arthritis
Asbestosis
Drugs e.g. amiodarone, nitrofurantoin
Idiopathic PF (IPF)
Other e.g. bronchiectasis, CTD e.g. SLE or systemic sclerosis, sjogren’s
Iatrogenic/Drug causes of Pulmonary Fibrosis
“BBC is everyMANS Gold”
Bleomycin
Busulphan
Cyclophosphamide
Methotrexate
Amiodarone
Nitrofurantoin
Sulphasalazine
Gold
Investigations for Pulmonary Fibrosis
LAB
- Routine bloods; ?eosinophilia on FBC (EAA)
- Immunoglobulins (ABPA)
- ACE (sarcoidosis)
- CK (myositis)
- Rheumatological screen e.g. ANA, RF, anti-DSNA, anti-Scl70, anti centromere
FUNCTIONAL
- Pulmonary function tests + DLCO
(Restrictive pattern with low DLCO)
- 6 minute walking test
RADIOLOGICAL
- CXR
- HRCT is key test
(Assess pattern, extent and distribution of fibrosis)
INVASIVE
- Bronchoscopy with Bronchoalveolar Lavage
- ?Lung biopsy
Management of Pulmonary Fibrosis
Depends on underlying cause
CONSERVATIVE
- Pulmonary rehab
PHARMACOLOGICAL
- Corticosteroids - less likely to respond if male/late presentation/honeycombing on CT/BAL neutrophilia
- Immunosuppression e.g. AZA/MTX
- Supplemental Oxygen
- Antifibrotics e.g. pirfenidone
(Specialist MDT decision, FVC 50-80%)
- Symptom Management e.g. benzos, opiates
SURGICAL
- Lung transplant may be suitable in some cases
What are the indications for lung transplant in UIP?
<65 years old
TLCO<40% predicted
Fall in FVC > 10% over 6 months
Rheumatoid Lung Disease
1) Pleural effusions/pleurisy
2) Pulmonary nodules
- Can precede arthritis
3) Fibrotic Lung disease
- Lower zone
4) Caplan Syndrome = coal worker’s pneumoconioses & RA
5) Obliterative Bronchiolitis
- Small airways obstructions –> necrotising bronchiolitis
- Linked to Gold & penicillamine
5 main types of pleural effusions
1) Transudates
- Raised hydrostatic or low oncotic pressures
2) Exudates
- Increased capillary permeability
3) Chylothorax
- Disruption of lymphatic ducts
4) Empyema
- Infection of pleural space
5) Haemothorax
- Bleeding into pleural space
Transudative Pleural Effusions
Pleural protein < 20g/L
CHAM
C- CCF
H - Hypoalbuminaemia / Hypothyroidism
A - All failures (liver, renal)
M - Meig’s syndrome (= benign ovarian fibroma & right sided effusion)
Exudative Pleural Effusions
Pleural protein >30g/L
PINTS
P -Pneumonia
I - Infarction (PE)
N - Neoplasia e.g. mesothelioma, metastases
T - TB/Trauma
S - Sarcoidosis/Scleroderma
What is Light’s Criteria?
Used if pleural protein level equivocal e.g. 25g/L
Pleural effusion is an EXUDATE if …
1) Pleural Albumin/Serum Albumin > 0.5
2) Pleural LDH/Serum LDH > 0.6
3) Pleural LDH > 2/3 of ULN of serum LDH
HOWEVER - 25% of transudates mistakenly identified as exudates using light’s criteria
Investigations for Pleural Effusions
Sputum MC&S +/- AFB
Bloods
- Routine
- ?Blood cultures
- Serum albumin and LDH
CXR
- >300mL to be seen on PA film
- >1000mL if mediastinal shift seen
USS
?CT thorax
?Bronchoscopy
?CT guided biopsy ?VATS
PLEURAL ASPIRATE TESTS
Pleural Fluid
- Cell Count
- Cytology
- Albumin & LDH (Light’s)
- Glucose
- pH (<7.2 = empyema!)
- Amylase (if suspicious of pancreatitis/oesophageal rupture)
- Lipids (if suspicious chylothorax)
What might a pleural fluid glucose <2.0 indicate?
Malignancy
Empyema
Arthritis (RA)
TB
What is the safety triangle for chest drain insertion?
Base of axilla
Lateral edge of pectoralis major
Lateral edge of latissimus dorsi
5th Intercostal Space
Management of Acute Tension Pneumothorax
Emergency! A to E
14 - 16 gauge cannula into 2nd or 3rd intercostal space, midclavicular line
Chest drain (safety triangle)
How would you manage a primary pneumothorax?
Primary pneumothorax = no history of underlying lung disease. Usually young, tall, thin men
A to E assessment
If <2cm and asymptomatic = supportive e.g. pain relief and oxygen therapy
If >2cm or symptomatic = aspirate with cannula in 2nd-3rd ICS
- If unsuccessful, chest drain
How would you manage a secondary pneumothorax?
Secondary pneumothorax = due to underlying respiratory disease e.g. Asthma, COPD
If <50 & <2cm & asymptomatic = Supportive +/- aspirate
If > 50 & > 2cm +/- symptoms = chest drain
Can you outline some advice we give to patients once they’ve had a pneumothorax?
Avoid smoking (increases risk of pneumoT)
No flying in 7 days after treatment
Avoid scuba diving for rest of life (unless undergo bilateral surgical pleurectomy)
Indications for Surgical Intervention for Pneumothorax
Persistent air leak
Repeat pneumothorax
- 1st contralateral
- 2nd ipsilateral
Bilateral spontaneous pneumothoraces
What is Obesity Hypoventilation Syndrome?
3 of
1) OSA
2) Hypercapnia
3) Restrictive PFTs
Investigating OSA
Epworth Sleepiness Scale
Overnight Polysomnography
- Measures ECG, EMG, resp effort and oxygenation overnight
- Number of apnoeas overnight
FBC (polycythaemia)
TFTs (?hypothyroidism)
Morning ABG
Management of OSA
CONSERVATIVE
- Advise weight loss if overweight (only 50% of OSA pts are obese)
- Stop smoking
- Reduce alcohol intake
MEDICAL
- CPAP = 1st line Rx but issues with compliance
- LTOT
Surgical intervention rare
Complications of OSA
HTN
IHD & MIs
Arrhythmias
Stroke
Pulmonary HTN
OHS
Outline the types of lung cancer
NON SMALL CELL LUNG CANCER
- Most common, 75-80%
- 3 main subtypes
= SCC > adenocarcinoa > large cell
SMALL CELL LUNG CANCER
- 20-25% of lung cancers
- Arise from APUD cells
- Rapidly growing with early metastases
Common sites of lung cancer metastases
Brain
Liver
Adrenal Glands
Bone - osteolytic appearance, often in vertebral bodies
Investigating for Lung Cancer
Lung Function Tests
- Suitability for surgical intervention
Sputum Cytology
- Positive in 20%
Bloods
- Routine (Na+ for SIADH, LFTs)
Imaging
CXR can be useful in first instance
CT CAP
- Evaluate tumour location & size, LNs & ?mets
- Identify site for biopsy
PET-CT scan
- More accurate at identifying mediastinal disease (?site for EBUS)
TISSUE SAMPLING
EBUS - nodal disease
CT guided biopsy - of mets or peripherally located cancer
Flexible bronchoscopy
Mediastinoscopy
VATS & pleural biopsy
Paraneoplastic Features of NSCLC
Parathyroid-hormone Related Protein Secretions
- Raised PTHrP = hypercalcaemia
- SCC
Hypertrophic Pulmonary Osteoarthropathy
- Clubbing and pain at wrist and ankles due to new bone formation
- Adenocarcinoma & SCC
BCG Secreting Tumour
- Gynaecomastia
- Adenocarcinoma & large cell
Management of NSCLC
Lung Cancer MDT
Consider if suitable for surgical resection
- Stage I or II TNM
- FEV1 >2L (if pneumonectomy); FEV1 > 1.5L (if lobectomy)
Radiotherapy
- Stage I - III if inoperable
Chemotherapy
- Post op or on its own
- Stage III-IV
Palliative Chemo/Radiotherapy if stage IV
Advanced Care Planning
Symptom control
Contraindications for Surgical Intervention for NSCLC
Stage IIIb/IV (mets present)
FEV1<1.5L
Malignant pleural effusion
Tumour near hilum
Vocal cord paralysis
SVCO
Left recurrent laryngeal nerve palsy
Paraneoplastic Features of SCLC
Ectopic ADH secretion
- = SIADH, with low sodium
Ectopic ACTH Secretion
- Cushing’s syndrome
= HTN, raised glucose, hypokalaemia, muscle weakness
Lambert-Eaton Myasthenic Syndrome (LEMS)
- Antibodies against VGCC
- Can precede diagnosis of lung cancer
How is SCLC staged and mangaged?
Staged as either:
1) Limited = disease confined to ipsilateral hemithorax = 15-20 months median survival
2) Extensive = metastatic disease outside ipsilateral hemithorax = 8-13 months median survival
MDT Approach
Unlikely to be suitable for surgical intervention
Combination of radiotherapy and chemotherapy
What is Pancoast’s Tumour?
Tumour in lung apex
Most commonly NSCLC (and usually SCC)
Invasive! - chest wall/ribs/brachial plexus/cervical sym nerves
PANCOAST’S SYNDROME =
Shoulder and arm pain along C8-T1 dermatomes
Horner’s Syndrome = miosis, ptosis, enophthalmos & anihydrosis
Hand muscle weakness & wasting
What is SVCO?
Superior Vena Cava Obstruction
Oncological emergency!
Most common in lung cancer (SCLC>NSCLC) and lymphoma
FEATURES
- Cough, SoB
- Headache, worse on bending forwards
- Syncope
- Hoarse voice
- Facial & upper limb oedema
- Facial plethora
- Superficial vein distension of upper body
- Fixed elevated JVP
- Inspiratory stridor
- Pemberton’s sign = facial swelling on lifting of both arms
How would you manage a patient with SVCO?
A to E assessment
Inform anaesthetic team and oncology team
Corticosteroids mainstay of treatment -
If evidence of respiratory compromise = IV dexamethasone
?Endovascular stenting
?Chemo/Radiotherapy (if unable to lie flat, unlikely to be able to tolerate radiotherapy)
Indications for Pneumonectomy/Lobectomy
Resection of lung malignancy
- NSCLC mainly (25% suitable)
Localised bronchiectasis with uncontrolled symptoms
Old TB (prior to pharmacological Rx)
Fungal infections e.g. aspergilloma
Traumatic lung injury
Large emphysematous bullae
CF
What FEV1 values do you need for a pneumonectomy?
FEV1 > 2L
What FEV1 values do you need for a lobectomy?
FEV1 > 1.5L
Indications for VATS
Lobectomy & pneumonectomy (less invasive)
Pleural biopsy
Lung parenchymal biopsy
Bullectomy & lung volume reduction for emphysema
Correction of spontaneous primary pnemothorax
Pleurodesis
Wedge resection
Benefits of VATs as opposed to “traditional” thoracic surgery
Minimally invasive
- Reduce need for muscle division & rib spreading/fractures
Quicker recovery
Reduced length of stay in hospital
Earlier mobilisation
Lower doses opiates/analgesics required
All adds up to reduce risks associated with hospital admissions e.g. HAI, delirium
Indications for Lung Transplant
ILD
Advanced COPD (usually single)
CF
Emphysema secondary to alpha1AT
Pulmonary HTN
Single = if >65 years old
Double = <60 years old
CRITERIA
- >50% chance of death within 2 years if no transplant
- >80% chance of survival >90 days
- >80% chance of 5yr survival
Contraindications for Lung Transplant
Severe organ dysfunction e.g. cardiac failure
Acute Critical Illness
Severe malnutrition/obesity
Smoking in last 6 months
Malignancy in last 5 years
Poor exercise tolerance/unable to walk
What is a Bullectomy?
= removal of giant bullae
Can help improve symptoms and lung function (restores mechanical linkage between chest wall and lungs)
Indications
1) Progressive SoB despite maximal Rx
AND
2) FEV1<50%
AND
3) Bullae>1/3 of hemithorax
What is Cor Pulmonale?
= enlargement and failure of right side of heart due to increased vascular resistance secondary to respiratory disorder e.g. COPD
Fluid retention & pulmonary HTN –> increased strain on RV –> RV failure
Best treatment = prevention!
Will likely need LTOT & diuretics
Signs of Bronchiectasis
Oxygen therapy
Sputum pots
Inhalers
Likely young if CF
Wet cough, ?cachexia
Clubbing, ?yellow nails
Midline/central line/portacath (?long term abx therapy)
?lymphadenopathy
Non deviated trachea
Coarse crackles
?Scars from previous lobectomy/wedge resection
COPD Spirometry Diagnostic Values
FEV1/FVC < 0.7
Severity:
FEV1 0.8 - 1.0 = mild
FEV1 0.5 - 0.8 = moderate
FEV1 0.3 - 0.5 = severe
FEV1 <0.3 = very severe
