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Respiratory for long case Flashcards

1
Q

Lung disease severity measures - history

A
  • Exercise tolerance, up flights stairs
  • Ability to be comfortable, speaking in sentences
  • Frequency of exacerbations
  • Frequency of hospital admissions
  • Frequency of respiratory infections
  • Frequency of intubations
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2
Q

Lung disease severity measures - exam

A
  • Respiratory rate
  • Acute irritability
  • Low sats and oxygen requirements
  • cyanosis
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3
Q

Lung disease severity measures - investigations

A
  • FEV1 and FVC
  • DLCO
  • Oxygen saturation and concentration on arterial blood gas
  • Degree of hypercapnoea and compensation for respiratory acidosis
  • Pulmonary pressure on TTE
  • VO2 max on exercise testing
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4
Q

Adherence measures/history - cardiorespiratory

A
  • Regular use of inhalers with correct use of spacer and medications
  • Smoking cessation
  • Peak expiratory flow measures on regular basis
  • Use of action plan
  • Regular GP and specialist appointments
  • Yearly influenza vaccinations, completed pneumococcal vaccinations
  • Avoidance of potential triggers
  • Involvement in rehabilitation and exercise program
  • Involvement of loved ones, community support in care
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5
Q

Bronchiectasis risk factors

A

recurrent childhood infections

immunodeficiency

abnormal mucociliary drainage – CF, kartager’s syndrome

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6
Q

complications of bronchiectasis

A

o Frequency of pneumonia, courses of antibiotics

o Abscess, empyema and thoracic decortication surgery (time of surgery, management, complications)

o Recurrent pleurisy – severity of symptoms, impact on life, management

o Colonisation with resistant organisms – recent cultures, eradication with Abx

o Pulmonary hypertension and right heart failure

o Bronchial haemorrhage requiring bronchoscopy and cautery

o Amyloidosis

o Other systemic infections (infective endocarditis)

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7
Q

Diagnosis of CF

A

CT

sweat testing

ciliary function testing

bronchoscopy

immunoglobulins

eosinophilia (allergic bronchopulmonary aspergillosis)

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8
Q

Treatment of bronchiectasis

A

o Sputum clearance

o Antibiotics

o Bronchodilators

o Inhaled steroids

o Oral steroids

o Twice daily postural drainage

o Vaccination

o Treatment of HF

o IV immunoglobulin

o Bronchoscopy of haemoptysis

o Lobectomies, wedge resections for localised drainage

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9
Q

Lung carcinoma - local symptoms

A

o Reduced exercise tolerance

o Pleural and thoracic chest pain (pleural and thoracic wall involvement)

o Dysphagia, hoarseness, stridor (tracheal and oesophageal obstruction)

o Headache and dizziness (superior vena caval obstruction)

o Bony pain, abdominal pain (metastasis)

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10
Q

lung carcinoma - systemic symptoms

A

o Loss of weight, appetite, night sweats

o New paraesthesia, weakness unsteadiness (LEMS, peripheral neuropathy, cerebellar degeneration, polymyositis and dermatomyositis, acute transverse myelitis)

o Limb pain, purpura (DVT, DIC)

o Polyuria (hypercalcaemia)

o Acanthosis nigricans, scleroderma

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11
Q

Lung carcinoma - investigations

A

o CT scans, biopsy -bronchoscopy or CT guided, VATS pleural, pleural tap

o Staging -CTCAP, PET scan

o PFTs for fitness for surgery FEV1 >1.5L

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12
Q

Lung carcinoma - treatment

A

o Chemotherapy – weekly/fortnightly course number of courses

 Antiemetic therapy, chemotherapy nursing support

 In hospital, clinic, home

o Radiotherapy

 Brain – prophylactic

 Chest –

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13
Q

Complications of lung carcinoma - disease

A

o Progression of local disease, metastasis – liver, abdominal, bony involvement

 Cord compression ascites biliary sepsis obstructive pneumonia DVT/PE

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14
Q

Complications of prednisolone treatment

A

 Myopathy

 Opportunistic infections

 Mania/psychosis

 Osteoporotic fractures

 Dysmorphic cushingoid features

 BSL derangements, refractory hypertension

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15
Q

Chemotherapy SEs lung cancer

A

 Nausea vomiting

 Mucositis

 Typhlitis, neutropaenic sepsis

 Peripheral neuropathy and pain

 Ototoxicity

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16
Q

Complications lung Ca - cancer pain

A

 Degree of opioid requirement

  • Number of rotations
  • Overdoses

 Local nerve blocks

 Functional loss due to pain

 Degree of sleep loss

 Degree of emotional distress

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17
Q

Measures of response - lung cancer

A

 Surveillance scans and PET post treatment course

 Blood counts, BMT myeloid/lymphoid malignant cell counts

 Blood tests – CA199, PSA

 Degree of functionality – walking, daily activities, ability to walk, moods  Level of pain

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18
Q

COPD precipitants

A

o Upper and lower respiratory tract infections

o Omission of medications

o Heart failure

o Sleep apnoea

o Pneumothorax

o GORD

o aspiration

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19
Q

COPD diagnosis

A

o Initial symptoms, spirometry – bronchodilator responsiveness, CT, arterial blood gases, FVC, FEV1

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20
Q

Complications of COPD

A

o Number of hospital admissions

o Number of exacerbations

o Number intubations

o Current exercise tolerance, flights of stairs, things unable to do

o FEV1, 6 minute walk test

o Oxygen concentration on arterial blood gas

o Current weight and degree of weight loss

o Pulmonary hypertension and right heart failure

o Lung cancer (separate issue)

o Depression (separate issue)

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21
Q

ECOG

A

0 Acute without restriction of performance

1 Ambulatory and able to attend light work activity, unable to carry out strenuous activity

2 Can manage self-care but unable to attend any form of work activity, ambulatory for more than 50% of the time while awake

3 Can manage one limited self care, bed bound for more than 50% of the time

4 Disabled, completely bed bound

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22
Q

Smoking - history

A

 Amount smoked

 Evidence of nicotine dependence –

smokes >10/day

30mins between smokes

smoking from waking

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23
Q

Smoking - high risk groups

A
  • Pregnancy
  • Parents of young children
  • Aboriginal and torres strait islanders
  • Mental illness
  • Other substance abuse
  • Lung disease
  • CVD risk factors and diabetes
  • Low socio-economic status
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24
Q

Smoking - Initial management

A

brief advice, motivational interviewing, quit date Follow up - Relapses occur in first few weeks of quitting and require follow up • Associated with weight gain, stress, and withdrawal symptoms

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25
Smoking - pharmacological therapy
 NRT increases quit rates by 60% from placebo, combination therapy oral and patch more effective than one alone CI – pregnancy, arrhthymias, lactation, CVD, angina, stroke  Varenicline – most effective, doubling abstinence rates, nausea; CI neuropsychiatric disease; however no increase in SI  Bupropion – effective with social support - CI in seizures, CNS disease, PD MAOI treatment; caution in DM, CKD, other drugs that may reduce seizure threshold
26
Current COPD treatment
o Bronchodilators and spacer o Domociliary oxygen – ABG, desaturation on 6MWT o Annual influenza vaccinations o BiPAP o Number of prednisolone courses o Pulmonary rehabilitation attendance, number of times, usefulness o Lung valves, lobectomies o Transplantation work up (separate issue) o Antiprotease therapy for alpha1 antitrypsin o Frusemide for RHF
27
COPD - asthma ddx
Non smoker Childhood onset Allergy Nocturnal symptoms Rapid response to treatment Eosinophila in sputum Bronchodilator reversibility Atopy
28
COPD - bronchiectasis ddx
Daily sputum expectoration Childhood recurrent chest infections, pertussis Clubbing
29
COPD examination
- Pursed lip breathing - Cyanosis/polycythaemia - Intercostal recession - Prolonged forced expiration - Tracheal tug - Reduced diaphragmatic movements - Reduced chest wall expansion - Hoover’s sign - Reduced breath sounds w/ wheeze - Sputum - RHF – parasternal heave, cv JVP, palpable P2, pulsatile liver - Cachexia
30
Sleep apnoea - history
- History – symptoms/concern leading to sleep study - Use of hypnotics - Evidence of paroxysmal nocturnal dyspnoa, orthopnoea, sensation of choking - Driving – heavy machinery licence, adherence to driving restrictions
31
Risk factors OSA
obesity daytime sleepiness alcohol hypertension atrial fibrillation GORD, COPD systolic heart failure deviated nasal septum nasopharyngeal deformity or tonsillar enlargement (if no obvious obesity)
32
Epworth sleepiness scale
o Reading o TV o Theatre or meeting o Driving as a passenger \> 1hr o Lying in afternoon o Sitting and talking o Sitting after lunch o Dozing at traffic lights
33
Components of sleep study
o Electroencephalogram o Apnoea/hypoapnoea index o Chin myogram o Electro-occular monitoring REM sleep o Sats probe o ECG overnight
34
Managment OSA
o Use of CPAP  Adherence, nose bridge ulcers, uncomfortable mask, dyspnoea/anxiety in mask  Improvement in sleepiness o Weightloss o Surgical correction of upper airway
35
OSA exam
- Malampatti score - Neck circumference - BMI - Hip/waist ratio - Acanthosis nigricans - Evidence of nasal bridge ulcers
36
Interstitial lung disease - symptom history
o Dry cough, worsening dysponea o History of pneumothorax, young woman o Systemic/rheumatic symptoms o History of asthma -\> Churg-Strauss syndrome o Haemoptysis/renal disease – Goodpastures/SLE
37
Interstitial lung disease - drug/RTx history
 Cardiac/anti-arrhythmic – amiodarone, procainamide  Hydralazine  Rheumatologic – MTX, penicillamine  Chemotherapeutics – bleomycin, bisulphin o Prior radiotherapy
38
Interstitial lung disease - rheumatic symptoms
Raynauds Polyarthritis Rashes Morning stiffness Generalised malaise, LOW, LOA, sweats Pleural lung disease, pericarditis
39
Interstitial lung disease - occupational history
 Silica, asbestos, coal  Nitrogen, chloride gas, ammonia gas  Brake fluid, vinyl chloride
40
Interstitial lung disease - Hypersensitivity exposure
 Bird, farmers – mouldy hay/grain  Cotton (byssinosis), flax/hemp dust o History of tuberculosis exposure
41
Interstitial lung disease - investigations
o CT chest – fibrosis, usual interstitial pneumonia (honey combing, subpleural basal predominance, traction bronchiectasis), Non-specific interstitial fibrosis o Brochoscopy and lavage w/ biopsy o ESR, CRP, ANA/ENA ABG
42
Interstitial lung disease - treatment
o Remove exposure, steroids – hypersensitivity, COP, sarcoidosis, CTD, histiocytosis X o Nifedipine o Lung Tx o Home O2
43
Investigations for pulmonary HTN
TTE, cardiac catheterisation, PFT, CT chest, V/Q, CTPA, HRCT, 6 minute walk test
44
Risk factors for Pul HTN
o Prior PE, COPD, heart failure, family history, gene testing (BMPR2), HIV, interstitial lung disease, sleep apnoea, scleroderma/MCTD
45
Medications for pul HTN
warfarin, bosentin, sildenafil, prostacyclin (SE: flushing)
46
History for sarcoidosis
o Systemic symptoms o Joint symptoms and rash o Eye involvement – uveitis o Sinusitis, parotiditis o Renal stones o Nerve palsies
47
Differentials for sarcoidosis
o Connective tissue disease -SLE – joint/rashes, mucosal involvements, RA, seronegative arthritis, sjogrens o Bechet’s disease – genital and mucosal ulcers, family history o Vasculitis – Granulomatous polyangiitis, eosinophilic polyangiitis, polyarteritis nodosa, GCA/PMR +/- glomerulonephritis o Antiphospholipid syndrome o Lymphoma, paraproteinaemia, POEMS, castleman’s o Subacute infective endocarditis o Atrial myxoma o Cholesterol emboli – recent angiography o Tick disease o Hypothyroidism/hyperthyroidism
48
Symptoms of hypercalcaemia in sarcoid
o Polyuria, polydipsia, confusion
49
Investigations for sarcoidosis
o ESR, CRP, ANA/ENA/ANCA, dsDNA, SPEP, immunoglobulins, TFTs, FBE, CMP, Vitamin D, CT chest, TTE, blood cultures bone marrow biopsy
50
Cystic fibrosis - systemic involvement
o Recurrent pneumonia, pleurisy, effusion, empyema and abscess o Bronchiectasis o Nasal polyps o Pancreatic failure - malabsorption, o small bowel obstruction o Focal biliary cirrhosis o Exocrine diabetes mellitus
51
Cystic fibrosis - investigations
o Sweat/chloride testing o PCR/DNA gene marker o Spirometry FEV1, CT scans o Sputum cultures, colonisation o FBE for anaemia of chronic disease, IDA, and B12 deficiency o LFTs, INR, abdominal USS, AFP, gastroscopy for varices
52
Cystic fibrosis - complications
o Haemoptysis o Pneumonia o Empyema o Pleurisy o Pneumothorax
53
Management of cystic fibrosis
o Physiotherapy o Exercise tolerance o Pancreatic enzyme supplementation o High fat diet o Recombinant DNAase - Transplantation work up o Regular appointments o Fertility, consideration of IVF
54
Indications for lung transplant
COPD FER \<25% cystic fibrosis PaCO2 \> 55, FER \< 30% ILD DLCO \<20%, symptoms eisenmengers, pulHTN – PAP \>55, cardiac index \<2L/min?
55
Contra-indications for lung transplant
Relative - T2DM ,osteoporosis, etOH, smoking, MAC/tuberculosis abscesus colonisation wt \>130% ideal \<70% ideal compliance Absolute HIV, HBV, HCV, malignancy \<5yrs
56
Transplant history
- Rejection - HLA matching - Infections – influenza, aspergillosis, CMV, myxomavirus, aspergillosis - Immunosuppression – renal transplant, hyperlipidaemia, post transplant lymphoproliferative disorders - Brochiolitis oliterans – chronic rejection,
57
COPD History
Smoking history, other substances Dust, gas exposure Chronic sputum production, cough Exercise tolerance Ankle swelling Loss of weight and appetite Frequency of exacerbation Vaccinations Previous lung surgery Recent PE/DVT, pneumothoracies Pulmonary rehab
58
Investigations for COPD
ABG PFT (FER \<0.7, TLC high, VC low, DLCO decreased); note that dyspnoea on minimal exertion correlates to FEV1 30% of predicted FBE Hb level, elevated if PaO2 is \<55; HCT \> 52% in males, 45% females signifies erythrocytosis indication for LTOT HRCT - for emphysema and other causes of lung dysfunction Sleep study - considered if PaO2 is high (\>60) in the presence of cor pulmonale and/or polycythemia Sputum culture indicative of moraxella catarrhalis, haemophilus influenzae and streptococcus pneumonia Steriod challenge for FER responsiveness
59
Smoking related complications
IHD Peripheral vascular disease Berger's disease of the peripheries Carcinoma of lung, head and neck, bladder, oesophagous, colon, renal Osteoporosis in women Erectile dysfunction in men Peptic ulcers Polycythemia ?Tobacco-alcohol amylopia
60
Management of COPD
Instruct patient on meds Steroids for exacerbation Inhalers - inhaled steroids, muscarinic antagonist, beta agonist - all long acting Phosphodiesterase 4 inhibitors Antibiotics - if acute, prophylactic drugs Quit smoking - nicotene patch, bupropion for anti-craving ?Oxygen supplementation - PaO2 \<55mmHg or \<88% sats at rest or asleep, PaO2 56-59 w/ cor pulmonale, RVH and p pulmonale on ECG, PCV \> 0.55 Frusemide if cor pulmonale present Consider transplant if \<55 yrs Nutritional advice Vaccinations (pneumococcal, influenza) ?Alpha-antitrypsin deficiency (treat w/ smoking cessation, tamoxifen or danazol)
61
Bronchiectasis History
Symptoms of cough and sputum production Frequency of exacerbation (record most recent and length of stay, management each time) Use of prophylactic antibiotics Previous postural drainage, chest physio and mucolytics Prior episodes of massive haemoptysis PHx - recurrent infections, including pertussis/whooping cough, measles, TB; Alcohol use, cystic fibrosis, immunodeficiency, HIV, Asthma Social set up - work and home stressor Depression
62
Bronchiectasis examination
RR, O2 sats, HR, BP Peripheral cyanosis, clubbing Hypertrophic pulmonary osteoarthropathy wrists and ankles Ausculation - coarse creps and wheeze Parasternal heave, loud P2, raised JVP, ascites, pitting oedema at peripheries, HSM Dextrocardia (right sided heart beat - Kartagener's syndrome)
63
Management of Bronchiectasis
Reduce secretions - Regular chest therapy, recombinant DNAse Prevent and treat exacerbations - Abx according to severity, regular bronchodilator +/- steroids Treat cor pulmonale and persistent hypoxia w/ frusemide and LTOT Treat Allergic Bronchopulmonary Aspergillosis w/ high dose steroids +/- antifungal therapy Treat hypogammaglobulinaemia w/ IV immunoglobulins Nutritional dietary supplements, availability of community based healthcare resources and psychological counselling
64
Cystic fibrosis history
Age of diagnosis Current respiratory symptoms Epistaxis - nasal polyps, sinonasal symptoms Recurrent admissions, abx therapy Physiotherapy Steatorrhoea (pancreatitis), intestinal obstruction (meconium ileus), RUQ pain (gallstones) Pancreatic enzyme supplementation Heat intolerance and exhaustion FHx of CF T2DM history Appetite, weightloss, pancreatic supplementation Reproductive plans
65
Investigations for Bronchiectasis and CF
CXR - cystic air spaces, air-fluid levels in dilated bronchi, thickened bronchial walls with peribronchial cuffing- appearance of tramlines and ring shadows HRCT PFTs - may be obstructive/restrictive or both Sputum microscopy and culture FBE - anaemia of chronic disease +/- chronic haemoptysis, eosinophilia (ABPA), low alb poor prognosis, ESR, CRP UEC for renal function Fibreoptic bronchoscopy, sweat chloride levels \>70mmol/L, serum immunoglobulin assay, sperm assay or respiratory mucosal Bx (Kartager's syndrome/ciliary dyskinaesia), skin tests and serology for aspergillosis
66
Management of Asthma
Optimise control - oral steroids required if SABA and IGCS not sufficient; LABA may be required if still not sufficient; leukotriene inhibitors for further control Revise inhaler technique Develop/revise asthma action plan - plan when symptoms worsen, PEFR measurements, self adjustment of meds, when to seek medical help Stop smoking influenza, pneumococcal vaccinations
67
Features of asthma clinical severity
Three or more of Daytime symptoms \> 2 per week Need for SABA \> 2 per week Any limitation of activities Any symptoms during night or waking

Long case clinical skills (12 decks)

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