Respiratory Gap Flashcards
Factors associated with poor prognosis of Sarcoidosis
insidious onset, symptoms > 6 months
absence of erythema nodosum
extrapulmonary manifestations: e.g. lupus pernio, splenomegaly
CXR: stage III-IV features
black African or African-Caribbean ethnicity
Indication of NIV in COPD
NIV should be considered in all patients with an acute exacerbation of COPD in whom a respiratory acidosis (PaCO2>6kPa, pH <7.35 ≥7.26) persists despite immediate maximum standard medical treatment
What type of NIV is used in COPD
BiPAP
BC
CPAP used in
It is used in conditions where the principal pathophysiology is type 1 respiratory failure i.e. pulmonary oedema/covid pneumonitis. It will not be effective in this scenario as the patient needs support with ventilation as well as oxygenation and therefore needs bilevel (i.e. oxygenation and ventilation) support.
also, OSA
HLA associations:
HLA-DR1: bronchiectasis
HLA-DR2: systemic lupus erythematous (SLE), Goodpasture
HLA-DR3: autoimmune hepatitis, primary Sjogren syndrome, type 1 diabetes Mellitus, SLE
HLA-DR4: rheumatoid arthritis, type 1 diabetes Mellitus
HLA-B27: ankylosing spondylitis, postgonococcal arthritis, acute anterior uveitis
Situations where oxygen therapy should not be used routinely if there is no evidence of hypoxia
Myocardial infarction and acute coronary syndromes
stroke
obstetric emergencies
anxiety-related hyperventilation
Oxygen therapy for COPD patients
Prior to availability of blood gases, use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis
adjust target range to 94-98% if the pCO2 is normal
Color of venturi mask
BLUE = 2-4L/min = 24% O2
WHITE = 4-6L/min = 28% O2
YELLOW = 8-10L/min = 35% O2
RED = 10-12L/min = 40% O2
GREEN = 12-15L/min = 60% O2
Causes of Bilateral Hilar Lymphadenopathy
The most common causes of bilateral hilar lymphadenopathy are sarcoidosis and tuberculosis.
Other causes include:
lymphoma/other malignancy
pneumoconiosis e.g. berylliosis
fungi e.g. histoplasmosis, coccidioidomycosis
ABPA story
Allergic bronchopulmonary aspergillosis results from an allergy to Aspergillus spores. In the exam questions often give a history of bronchiectasis and eosinophilia.
Features
bronchoconstriction: wheeze, cough, dyspnoea. Patients may have a previous label of asthma
bronchiectasis (proximal)
Investigations
eosinophilia
flitting CXR changes
positive radioallergosorbent (RAST) test to Aspergillus
positive IgG precipitins (not as positive as in aspergilloma)
raised IgE
Management
oral glucocorticoids
itraconazole is sometimes introduced as a second-line agent
What is ABPA
Allergic bronchopulmonary aspergillosis results from an allergy to Aspergillus spores. In the exam questions often give a history of bronchiectasis and eosinophilia.
Features of ABPA
bronchoconstriction: wheeze, cough, dyspnoea. Patients may have a previous label of asthma
bronchiectasis (proximal)
Rx of ABPA
oral glucocorticoids
itraconazole is sometimes introduced as a second-line agent
high-risk characteristics for Pneumothorax
Haemodynamic compromise (suggesting a tension pneumothorax)
significant hypoxia
bilateral pneumothorax
underlying lung disease
≥ 50 years of age with significant smoking history
haemothorax
Fitness to fly advice for Pneumothorax
absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray
NICE recommendation for Smoking cessation
Nicotine replacement therapy (NRT)
Varenicline
Bupropion
What is Buproprion
a norepinephrine-dopamine reuptake inhibitor and nicotinic antagonist
unlike many antidepressants it has a minimal effect on serotonin
should be started 1 to 2 weeks before the patient’s target date to stop
small risk of seizures (1 in 1,000)
contraindicated in epilepsy, pregnancy and breast feeding. Having an eating disorder is a relative contraindication
Buproprion contraindicated in
contraindicated in epilepsy, pregnancy and breast feeding. Having an eating disorder is a relative contraindication
who to refer to NHS Stop Smoking Service in Pregnancy
All women who smoke, or have stopped smoking within the last 2 weeks, or those with a CO reading of 7 ppm or above should be referred to NHS Stop Smoking Services.
First line for smoking cessation in pregnancy
CBT
Varenicline
a nicotinic receptor partial agonist
should be started 1 week before the patients target date to stop
the recommended course of treatment is 12 weeks (but patients should be monitored regularly and treatment only continued if not smoking)
has been shown in studies to be more effective than bupropion
nausea is the most common adverse effect. Other common problems include headache, insomnia, abnormal dreams**
varenicline should be used with caution in patients with a history of depression or self-harm. There are ongoing studies looking at the risk of suicidal behaviour in patients taking varenicline
contraindicated in pregnancy and breastfeeding**
Varenicline is contraindicated in
contraindicated in pregnancy and breastfeeding
Which one of the following pathophysiological changes is most responsible for emphysema?
Destruction of alveolar walls secondary to Proteinases
COPD management
photo
criteria to determine whether a patient has asthmatic/steroid responsive features:
- any previous, secure diagnosis of asthma or of atopy
- a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
- substantial variation in FEV1 over time (at least 400 ml)
- substantial diurnal variation in peak expiratory flow (at least 20%)
Asthma Exacerbation class
Moderate:
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
Severe:
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
Life-Threatening:
PEFR < 33% best or predicted
Oxygen sats < 92%
‘Normal’ pC02 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
Predisposing factors for OSA
obesity
macroglossia: acromegaly, hypothyroidism, amyloidosis
large tonsils
Marfan’s syndrome
Rx for OSA
Management
weight loss
continuous positive airway pressure (CPAP) is first line for moderate or severe OSAHS
intra-oral devices (e.g. mandibular advancement) may be used if CPAP is not tolerated or for patients with mild OSAHS where there is no daytime sleepiness
the DVLA should be informed if OSAHS is causing excessive daytime sleepiness
limited evidence to support use of pharmacological agents
Genotype for A1AT Deficiency
For anyone who cannot remember the PiMM, PiSS, PiZZ, remember in an alphabet list, M comes first then S and last Z so… PiMM = normal., PiSS = 50% and PiZZ = Zero.
Also this:
Normal PiMM > PiMS > PiMZ > PiSS > PiSZ > PiZZ Abnormal
PIZZ - last letter in the alphabet - therefore the worst.
PIMM - the best, no carrier, not ill
PiSS – Slow on electrophoresis. Unlikely to be symptomatic.
PIMZ: carrier and unlikely to develop emphysema if a non-smoker
A1AT Features
located on chromosome 14
inherited in an autosomal recessive / co-dominant fashion*
Features
Lungs: panacinar emphysema, most marked in lower lobes
Liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
Investigations
A1AT concentrations
spirometry: obstructive picture
Management:
- no smoking
- supportive: bronchodilators, physiotherapy
- intravenous alpha1-antitrypsin protein concentrates
** - surgery: lung volume reduction surgery, lung transplantation**
Klebsiella pneumoniae is a Gram——— bacilli?/cocci? that is part of the normal ——
Klebsiella pneumoniae is a Gram-negative rod that is part of the normal gut flora
Red currant Jelly sputum is caused by
Klebsiella
Klebsiella is common in
Alcoholics and Diabetics
Spirometry in A1At
Obstructive
Causes of Upper zone pulmonary fibrosis:
Causes of upper zone pulmonary fibrosis:
CHARTS
Coal workers pneumoconiosis
Hypersensitivity pneumonitis, histiocytosis
Ankylosing spondylitis
Radiation
Tuberculosis
Silicosis, sarcoidosis
Causes of lower zone pulmonary fibrosis
ACID
Asbestosis
C- connective tissue diseases (e.g. rheumatoid arthritis)
Idiopathic pulmonary fibrosis
Drugs (e.g. methotrexate)
Type of hypersensitivity in Extrinsic Allergic Alveolitis
It is thought to be largely caused by **immune-complex mediated tissue damage (type III hypersensitivity) **although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase.
Examples of Extrinsic Allergic Alveolitis
bird fanciers’ lung: avian proteins from bird droppings
farmers lung: spores of Saccharopolyspora rectivirgula from wet hay (formerly Micropolyspora faeni)
malt workers’ lung: Aspergillus clavatus
mushroom workers’ lung: thermophilic actinomycetes*
BAL Finding of Extrinsic Allergic Alveolitis
Blood finding of EAA
bronchoalveolar lavage: lymphocytosis
blood: NO eosinophilia
What is TLCO
The transfer factor describes the rate at which a gas will diffuse from alveoli into blood. Carbon monoxide is used to test the rate of diffusion. Results may be given as the total gas transfer (TLCO) or that corrected for lung volume (transfer coefficient, KCO)
Relation Between TLCO and KCO
TLCO = KCO x Alveolar volume (VA)
Granulomatosis with Polyangitis also known as
Wegner’s Granulomatosis
It commonly affects the;
upper respiratory tract (chronic sinusitis)
lungs (haemoptysis due to pulmonary haemorrhage, leading to raised TLCO), and kidneys (glomerulonephritis causing proteinuria and haematuria). The presence of c-ANCA is strongly associated with GPA
Causes of a raised TLCO
asthma
pulmonary haemorrhage (e.g. granulomatosis with polyangiitis, Goodpasture’s)
left-to-right cardiac shunts
polycythaemia
hyperkinetic states
male gender, exercise
blood flow barabe jara lungs e tara shobai TLCO barabe
Causes of a lower TLCO
pulmonary fibrosis
pneumonia
pulmonary emboli
pulmonary oedema
emphysema
anaemia
low cardiac output
active lung volume jodi kome jay- or blood flow jodi kome
Features of ASD
The fixed splitting of the second heart sound and the systolic murmur at the left upper sternal edge are classic clinical signs of an ASD
TLCO in chronic bronchitis- normal/raised/decreased
Normal
TLCO in emphysema- normal/raised/decreased
Decreased
Relation of TLCO vs KCO
TLCO = KCO x Alveolar volume (VA)
Small Cell Lung Cancer Associated with
Hyponatremia
How to diagnose Asthma in Children
Children 5-16 years
all children should have spirometry with a bronchodilator reversibility (BDR) test
+
a FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative bronchodilator reversibility (BDR) test
i am a simple man, i see cherry red lesion i choose ———-
i see alcoholic or diabetic with pneumonia i choose ——–
i see pneumonia in immunosupprssed, without or with less chest findings i ——-
i see fever, retroorbital headache, rash, thrombocytopenia, in a travellar i choose ——
i see pleural plaques i choose ——
i see….
i seee….
i am a simple man, i see cherry red lesion i choose lung carcinoid.
i see alcoholic or diabetic with pneumonia i choose klebsiella.
i see pneumonia in immunosupprssed, without or with less chest findings i choose pneumocystis jiroveci.
i see fever, retroorbital headache, rash, thrombocytopenia, in a travellar i choose** dengue.
i see pleural plaques i choose no follow up.**
i see….
i seee….
Lung carcinoid Bronch finding
Cherry red ball lesion
bronchiolitis obliterans
bronchiolitis obliterans
progressive dyspnoea
obstructive pattern on spirometry
centrilobular nodules, bronchial wall thickening is seen on CT
can be a presentation of Rheumatoid lung disease
Why use ICS in COPD
reduced exacerbations
SCC of Lungs associated with
sQuamous cell Carcinoma
–> The sound of K points to:
HyperCalcemia (elevated PTHrP)
Cavitating lesions
think like SCC
smoking
Calcium
Cavity
D/d of Cavitary lesion in the Xray
Differential
abscess (Staph aureus, Klebsiella and Pseudomonas)
squamous cell lung cancer
tuberculosis
Wegener’s granulomatosis
pulmonary embolism
rheumatoid arthritis
aspergillosis, histoplasmosis, coccidioidomycosis
Lung cancer associations
Small Cell
SCC
Adeno
Small cell - SVC obstruction
Squamous cell - cavity
Adeno - trousseau syndrome and clubbing
Psittacosis should be suspected in a combination of——
Psittacosis should be suspected in a combination of typical fever with a history of bird contact (reported in 84%) or a presentation with pneumonia and severe headache or organomegaly and failure to respond to penicillin-based antibiotics.
Rx of Psittacosis
Treatment:
1st-line: tetracyclines e.g. doxycycline
2nd-line: macrolides e.g. erythromycin
Contraindication to Lung cancer surgery
assess general health
stage IIIb or IV (i.e. metastases present)
FEV1 < 1.5 litres is considered a general cut-off point*
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction
Risk factors for lunh cancer
smoking
+
asbestos - increases risk of lung ca by a factor of 5
arsenic
radon
nickel
chromate
aromatic hydrocarbon
cryptogenic fibrosing alveolitis
Factors that are NOT related
coal dust
NARCOS
Nickel
Asbestos, Arsenic, Aromatic HC
Radon
Cryptogenic FA
Omitt
Smoking
Dx Criteria for ARDS
acute onset (within 1 week of a known risk factor)
pulmonary oedema: bilateral infiltrates on chest x-ray (‘not fully explained by effusions, lobar/lung collapse or nodules)
non-cardiogenic (pulmonary artery wedge pressure needed if doubt)
pO2/FiO2 < 40kPa (300 mmHg)
Asbestos exposure can cause
Pleural Plaque
Pleural Thickening
Asbestosis
Mesothelioma
Lung Cancer
Rx for Mesothelioma
Palliative Chemo.
Little role for Radio and Surgery
Most dangerous form of Mesothelioma
Crocidolite (blue) asbestos is the most dangerous form.
Spirometry findings in Asbestosis
Gas Transfer in Asbestosis
lung function tests show a restrictive pattern with reduced gas transfer
What feature of lung metastasis is found in chondrosarcoma or osteosarcoma
Calcification
Type of metastatic features
Miliary: Kidney on its side => battleship => cannonball metastases with miliary (military) pattern. M for melanoma
Haemorrhagic: cHoriocarcinoma + angio (blood) sarcoma
Adenocarcinoma: Alveolar spread (=> consolidation)
Calcification: lots of calcium in cartilage/bones - osteosarcoma + chondrosarcoma
Cavitation: we love VQ scanning for the lungs - caV =? sQuamous
Indication for placement of chest tube in Pleural Effusion?
Indication for ventilation and intubation in Asthma?
Indication for LTOT in COPD?
Contraindication for lung cancer resection?Indication for NIV in COPD?
pH<7.2 - Indication for placement of chest tube in Pleural Effusion.
PH <7.35 - Indication for ventilation and intubation in Asthma.
PO2<7.3 - Indication for LTOT.
FEV1 <1.5 - Contraindication for lung cancer resection.
96 MetaMegaly - 28 Nov 22
pH 7.25-7.35 - Indication for NIV in COPD.
Signs of Life Threatening Asthma
PEFR < 33% best or predicted
Oxygen sats < 92%
‘Normal’ pC02 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
Commonest chemical for occupaitonal asthma
Isocyanate
Inv for occupational asthma
Serial measurements of peak expiratory flow are recommended at work and away from work.
Referral should be made to a respiratory specialist for patients with suspected occupational asthma.
Risk factor for TB
Silicosis
Occupations at tisk of silicosis
Mining
slate works
foundries
potteries
Causes of Bronchiectasis
post-infective: tuberculosis, measles, pertussis, pneumonia
cystic fibrosis
bronchial obstruction e.g. lung cancer/foreign body
immune deficiency: selective IgA, hypogammaglobulinaemia
allergic bronchopulmonary aspergillosis (ABPA)
ciliary dyskinetic syndromes: Kartagener’s syndrome, Young’s syndrome
yellow nail syndrome
Lofgrens Syndrome
This patient is suffering from Lofgren’s syndrome - a pattern of sarcoidosis symptoms encompassing **fever, joint pain, erythema nodosum, lymphadenopathy and bilateral hilar lymphadenopathy. **
Needs monitoring only
Contraindication of Surgical Resection of Lung Cancer
ROPE
Reduced FEV1 <1.5,
Obstruction of the SVC
Paralysis of vocal cords
Effusion (malignant)
+
tumour near hilum
Insertion of a chest drain is relatively contraindicated in patients with any of the:
Insertion of a chest drain is relatively contraindicated in patients with any of the following:
INR > 1.3
Platelet count < 75
Pulmonary bullae
Pleural adhesions
Removal of Chest Drain
Removal of the chest drain is dependent upon the indication for insertion:
- In cases of fluid drainage from the pleural cavity, the drain should be removed when there has been no output for > 24 hours and imaging shows resolution of the fluid collection.
- In cases of pneumothorax, the drain should be removed when it is no longer bubbling spontaneously or when the patient coughs and ideally when imaging shows resolution of the pneumothorax.
- Drains inserted in cases of penetrating chest injury should be reviewed by the specialist to confirm an appropriate time for removal.
What to do if Re explansion Pulmonary edema is suspected
Re-expansion pulmonary oedema may be preceded by the onset of a cough and/or shortness of breath. In the event of concerns regarding re-expansion pulmonary oedema, the chest drain should be clamped and an urgent chest x-ray should be obtained
How to avoid re expansion pulmonary pulmonary edema
To avoid re-expansion pulmonary oedema, it is recommended that the drain tubing should be clamped regularly in the event of rapid fluid output i.e. drain output should not exceed 1L of fluid over a short period of time (less than 6 hours)
Drugs causing Fibrosis
drug-induced:
Be-DAMN
Bleomycin
Dopamine agonists
Amiodarone
Methotrexate
Nitrofurantoin
lower zone
Kartagener’s syndrome (also known as primary ciliary dyskinesia) features
dextrocardia or complete situs inversus
bronchiectasis
recurrent sinusitis
subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)
dextrocardia or complete situs inversus
bronchiectasis
recurrent sinusitis
subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)dextrocardia or complete situs inversus
Kartagener’s syndrome (also known as primary ciliary dyskinesia) features
Contraindication to lung transplant in CF
chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation
Drug used for CF
Lumacaftor/Ivacaftor (Orkambi)
- is used to treat cystic fibrosis patients who are homozygous for the delta F508 mutation
- lumacaftor increases the number of CFTR proteins that are transported to the cell surface
- ivacaftor is a potentiator of CFTR that is already at the cell surface, increasing the probability that the defective channel will be open and allow chloride ions to pass through the channel pore
What are the altitude related disorders
acute mountain sickness (AMS)
High altitude pulmonary oedema (HAPE)
High altitude cerebral oedema (HACE).
Management of HAPE
descent
nifedipine, dexamethasone, acetazolamide, phosphodiesterase type V inhibitors*
oxygen if available
Management of HACE
descent
dexamethasone
Predention of AMS
Prevention and treatment of AMS
the risk of AMS may actually be positively correlated to physical fitness
gain altitude at no more than 500 m per day
acetazolamide (a carbonic anhydrase inhibitor) is widely used to prevent AMS and has a supporting evidence base
it causes a primary metabolic acidosis and compensatory respiratory alkalosis which increases respiratory rate and improves oxygenation
treatment: descent
How does Acetazolamide prevent AMS
acetazolamide (a carbonic anhydrase inhibitor) is widely used to prevent AMS and has a supporting evidence base
it causes a primary metabolic acidosis and compensatory respiratory alkalosis which increases respiratory rate and improves oxygenation
treatment: descent
Classical Presentation of Churg Strauss
The diagnosis here is eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome. This is evidenced by the history of asthma, allergic rhinitis, presentation with mononeuritis multiplex (the most common vasculitic manifestation of EGPA) and eosinophilia. Classically, pANCA is positive in this condition and used to aid diagnosis.
(conversely-
ECG— granulomatosis with polyengitis e cANCA positive.
okhane sinusitis thakena.
Indications for steroids in Sarcoidosis
patients with chest x-ray stage 2 or 3 disease who are symptomatic. Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment
hypercalcaemia
eye, heart or neuro involvement
XRay finding of Silicosis
The typical chest X-ray findings in chronic silicosis are multiple and small well-rounded nodules, particularly in the upper zone. As the disease progresses the hilar retracts upwards and cavitation can occur leading to the potential for a secondary tuberculosis infection. Classically, eggshell calcification is seen on imaging.
Genetics of CF
Cystic fibrosis (CF) is an autosomal recessive disorder causing increased viscosity of secretions (e.g. lungs and pancreas). It is due to a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which codes a cAMP-regulated chloride channel
Occupational Asthma caused by
isocyanates - the most common cause
example occupations include spray painting and foam moulding using adhesives
platinum salts
soldering flux resin
glutaraldehyde
flour
epoxy resins
proteolytic enzymes
Initial NIV Setup for COPD
Recommended initial settings for bi-level pressure support in COPD
Expiratory Positive Airway Pressure (EPAP): 4-5 cm H2O
Inspiratory Positive Airway Pressure (IPAP): RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O
back up rate: 15 breaths/min
back up inspiration:expiration ratio: 1:3
LTOT in COPD
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension
Factors shifting Ox disscoaiaton curve to right
Causes Raised oxygen delivery:
Raised acidity
Raised temp
Raised 2-3 DPG
Factors shifting Ox disscoaiaton curve to Left
shifts Left - Lower oxygen delivery
Lower acidity
Low temp
Low 2-3 DPG
+
HbF, methaemoglobin, carboxyhaemoglobin
Transudative Pleural Effusion Meaning
Transudate (< 30g/L protein)
Causes of Transudative Effusion
Transudate (< 30g/L protein)
(remember Transudate: all the failures (hypothroid, heart failures, liver failure, liver failure) + meigs syndrome…. it kinda works)
Trans der kom thake + tara fail kore
heart failure (most common transudate cause)
hypoalbuminaemia
liver disease
nephrotic syndrome
malabsorption
hypothyroidism
Meigs’ syndrome
Exudatiove Effusion meaning
Exudate (> 30g/L protein)
Causes of exudative effusion
Exudate (> 30g/L protein)
infection
pneumonia (most common exudate cause),
tuberculosis
subphrenic abscess
connective tissue disease
rheumatoid arthritis
systemic lupus erythematosus
neoplasia
lung cancer
mesothelioma
metastases
pancreatitis
pulmonary embolism
Dressler’s syndrome
yellow nail syndrome
Malignancy causes —— type of effusion
Exudative
Indications for corticosteroid treatment for sarcoidosis are
parenchymal lung disease, uveitis, hypercalcaemia and neurological or cardiac involvement
Paraneoplastic Features of Lung Cancer
Small> at the level of head
Squamous> at the level of neck
Adenocarcinoma> at the level of breast
Small cell- AAL
ADH
ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc
Lambert-Eaton syndrome
Squamous cell
parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
clubbing
hypertrophic pulmonary osteoarthropathy (HPOA)
hyperthyroidism due to ectopic TSH
Adenocarcinoma
gynaecomastia
hypertrophic pulmonary osteoarthropathy (HPOA)
Paraneoplastic feature of small cell lung cancer
Small> at the level of head
Squamous> at the level of neck
Adenocarcinoma> at the level of breast
Small cell- AAL
ADH- Hyponatremia
ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc- CUshing
Lambert-Eaton syndrome
Paraneoplastic feature of SCC
Squamous cell
parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
clubbing
hypertrophic pulmonary osteoarthropathy (HPOA)
hyperthyroidism due to ectopic TSH
Respiratory acidosis may be caused by a number of conditions
Respiratory acidosis
Respiratory acidosis may be caused by a number of conditions:
COPD
decompensation in other respiratory conditions e.g. life-threatening asthma / pulmonary oedema
neuromuscular disease
obesity hypoventilation syndrome
sedative drugs: benzodiazepines, opiate overdose
Benzo and Opiate Overdose causes
Resp Acidosis
Poor Prognosis of Pneumonia
High Urea >7
Now Sodium <130
Lights Criteria for Pleural Effusion
Light’s criteria was developed in 1972 to help distinguish between a transudate and an exudate. The BTS recommend using the criteria for borderline cases:
exudates have a protein level of >30 g/L, transudates have a protein level of <30 g/L
if the protein level is between 25-35 g/L, Light’s criteria should be applied. An exudate is likely if at least one of the following criteria are met:
pleural fluid protein divided by serum protein >0.5
pleural fluid LDH divided by serum LDH >0.6
pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
To remember values for proten LDH
Protein = penta >0.5 exudate
LdH =hexa =6 = >0.6 ratio exudate
When is Lights criteria for Pleural Effusion Applicable
if the protein level is between 25-35 g/L, Light’s criteria should be applied.
Causes of Pulmonary Eosinophilia
WE LATCHED onto pulm eosinophilia:
WEgener’s
Loffler’s (transient rxn to parasites, self limiting)
ABPA
Tropical pulm eosinophilia
Churg-Strauss
Hypereosinophilic syndrome
Eosinophilic pneumonia
Drugs - nitro, sulfonamides
You have lung cancer but you have never smoked. What type is it?
Adeno
Good way to remember:
‘How’d you get lung ca when you don’t smoke?’
‘Adeno’
Define PH
Pulmonary hypertension may be defined as a sustained elevation in mean pulmonary arterial pressure of greater than 20 mmHg at rest
Group 1: Pulmonary arterial hypertension (PAH)
- idiopathic*
- familial
- associated conditions: collagen vascular disease, congenital heart disease with systemic to pulmonary shunts, HIV**, drugs and toxins, sickle cell disease
- persistent pulmonary hypertension of the newborn
Group 2: Pulmonary hypertension with left heart disease
- left-sided atrial, ventricular or valvular disease such as left ventricular systolic and diastolic dysfunction, mitral stenosis and mitral regurgitation
Group 3: Pulmonary hypertension secondary to lung disease/hypoxia
- COPD
- interstitial lung disease
- sleep apnoea
- high altitude
Group 4: Pulmonary hypertension due to thromboembolic disease
Group 5: Miscellaneous conditions
- lymphangiomatosis e.g. secondary to carcinomatosis or sarcoidosis
causes of resp alkalosis
anxiety leading to hyperventilation
pulmonary embolism
salicylate poisoning*
CNS disorders: stroke, subarachnoid haemorrhage, encephalitis
altitude
pregnancy
Pneumothorax in menstruating lady
Catamenial pneumothorax is the cause of 3-6% of spontaneous pneumothoraces occurring in menstruating women. It is thought to be caused by endometriosis within the thorax.
Spirometry and TLCO in Cryptogenic Pneumonia
Lung function tests are most commonly restrictive but can be obstructive or normal. The transfer factor is reduced.
Which parameter of the lung volume curve is reduced in obesity
ERV
All Lung Volume Curve issues
Inspiratory capacity = Tidal volume + Inspiratory reserve volume
Expiratory reserve volume may be significantly reduced in obese patients
Vital capacity: 4,500ml in males, 3,500ml in females
Vital capacity is the maximum volume of air that can be expired after a maximal inspiration
Functional residual capacity = Expiratory reserve volume + Residual volume
Total lung capacity is the sum of vital capacity + residual volume
——— should be suspected in the presentation of dyspnoea and hypoxaemia around 72 hours postoperatively
Atelectasis
Indication of Chest Drain in Pleural Effusion
Pleural infection
All patients with a pleural effusion in association with sepsis or a pneumonic illness require diagnostic pleural fluid sampling
if the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage
if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed
is the investigation of choice for upper airway compression
Flow volume loop is the investigation of choice for upper airway compression
malt workers’ lung caused by
Farmers lung caused by
malt workers’ lung: Aspergillus clavatus
farmers lung: spores of Saccharopolyspora rectivirgula from wet hay (formerly Micropolyspora faeni)
Dietary advice for CF
The correct answer is High calorie and high fat with pancreatic enzyme supplementation for every meal. Patients with cystic fibrosis (CF) have an increased energy requirement due to the chronic inflammation and i
