Respiratory for long case Flashcards
Lung disease severity measures - history
- 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
Lung disease severity measures - exam
- Respiratory rate
- Acute irritability
- Low sats and oxygen requirements
- cyanosis
Lung disease severity measures - investigations
- 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
Adherence measures/history - cardiorespiratory
- 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
Bronchiectasis risk factors
recurrent childhood infections
immunodeficiency
abnormal mucociliary drainage – CF, kartager’s syndrome
complications of bronchiectasis
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)
Diagnosis of CF
CT
sweat testing
ciliary function testing
bronchoscopy
immunoglobulins
eosinophilia (allergic bronchopulmonary aspergillosis)
Treatment of bronchiectasis
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
Lung carcinoma - local symptoms
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)
lung carcinoma - systemic symptoms
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
Lung carcinoma - investigations
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
Lung carcinoma - treatment
o Chemotherapy – weekly/fortnightly course number of courses
Antiemetic therapy, chemotherapy nursing support
In hospital, clinic, home
o Radiotherapy
Brain – prophylactic
Chest –
Complications of lung carcinoma - disease
o Progression of local disease, metastasis – liver, abdominal, bony involvement
Cord compression ascites biliary sepsis obstructive pneumonia DVT/PE
Complications of prednisolone treatment
Myopathy
Opportunistic infections
Mania/psychosis
Osteoporotic fractures
Dysmorphic cushingoid features
BSL derangements, refractory hypertension
Chemotherapy SEs lung cancer
Nausea vomiting
Mucositis
Typhlitis, neutropaenic sepsis
Peripheral neuropathy and pain
Ototoxicity
Complications lung Ca - cancer pain
Degree of opioid requirement
- Number of rotations
- Overdoses
Local nerve blocks
Functional loss due to pain
Degree of sleep loss
Degree of emotional distress
Measures of response - lung cancer
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
COPD precipitants
o Upper and lower respiratory tract infections
o Omission of medications
o Heart failure
o Sleep apnoea
o Pneumothorax
o GORD
o aspiration
COPD diagnosis
o Initial symptoms, spirometry – bronchodilator responsiveness, CT, arterial blood gases, FVC, FEV1
Complications of COPD
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)
ECOG
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
Smoking - history
Amount smoked
Evidence of nicotine dependence –
smokes >10/day
30mins between smokes
smoking from waking
Smoking - high risk groups
- 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
Smoking - Initial management
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
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
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
COPD - asthma ddx
Non smoker
Childhood onset
Allergy
Nocturnal symptoms
Rapid response to treatment
Eosinophila in sputum
Bronchodilator reversibility
Atopy
COPD - bronchiectasis ddx
Daily sputum expectoration
Childhood recurrent chest infections, pertussis
Clubbing
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
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
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)
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
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
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
OSA exam
- Malampatti score
- Neck circumference
- BMI - Hip/waist ratio
- Acanthosis nigricans
- Evidence of nasal bridge ulcers
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
Interstitial lung disease - drug/RTx history
Cardiac/anti-arrhythmic – amiodarone, procainamide
Hydralazine
Rheumatologic – MTX, penicillamine
Chemotherapeutics – bleomycin, bisulphin
o Prior radiotherapy
Interstitial lung disease - rheumatic symptoms
Raynauds
Polyarthritis
Rashes
Morning stiffness
Generalised malaise, LOW, LOA, sweats
Pleural lung disease, pericarditis
Interstitial lung disease - occupational history
Silica, asbestos, coal
Nitrogen, chloride gas, ammonia gas
Brake fluid, vinyl chloride
Interstitial lung disease - Hypersensitivity exposure
Bird, farmers – mouldy hay/grain
Cotton (byssinosis), flax/hemp dust
o History of tuberculosis exposure
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
Interstitial lung disease - treatment
o Remove exposure, steroids – hypersensitivity, COP, sarcoidosis, CTD, histiocytosis X
o Nifedipine
o Lung Tx
o Home O2
Investigations for pulmonary HTN
TTE, cardiac catheterisation, PFT, CT chest, V/Q, CTPA, HRCT, 6 minute walk test
Risk factors for Pul HTN
o Prior PE, COPD, heart failure, family history, gene testing (BMPR2), HIV, interstitial lung disease, sleep apnoea, scleroderma/MCTD
Medications for pul HTN
warfarin, bosentin, sildenafil, prostacyclin (SE: flushing)
History for sarcoidosis
o Systemic symptoms
o Joint symptoms and rash
o Eye involvement – uveitis
o Sinusitis, parotiditis
o Renal stones
o Nerve palsies
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
Symptoms of hypercalcaemia in sarcoid
o Polyuria, polydipsia, confusion
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
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
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
Cystic fibrosis - complications
o Haemoptysis
o Pneumonia
o Empyema
o Pleurisy
o Pneumothorax
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
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?
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
Transplant history
- Rejection
- HLA matching
- Infections
– influenza, aspergillosis, CMV, myxomavirus, aspergillosis
- Immunosuppression – renal transplant, hyperlipidaemia, post transplant lymphoproliferative disorders
- Brochiolitis oliterans
– chronic rejection,
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
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
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
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)
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
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)
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
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
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
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
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
