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Yr 4 - CCC > Respiratory: Pulmonary Fibrosis, Bronchiectasis & Pleural Effusion > Flashcards

Respiratory: Pulmonary Fibrosis, Bronchiectasis & Pleural Effusion Flashcards

1
Q

What is a pleural effusion?

A

A pleural effusion is a collection of fluid in the pleural space.

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2
Q

What are the 2 categories of pleural effusion?

A

1) Exudative

2) Transudative

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3
Q

What defines an exudative pleural effusion?

A

HIGH protein count (>35g/L)

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4
Q

What defines a transudative pleural effusion?

A

LOWER protein count (<25g/L)

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5
Q

What criteria is used for establishing an exudative effusion?

A

Light’s criteria

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6
Q

What does Light’s criteria for establishing an exudative effusion take into account?

A

1) Fluid protein/serum protein –> >0.5

2) Fluid LDH/serum LDH –> >0.6

3) Pleural fluid LDH greater than 2/3 of the normal upper limit of the serum LDH

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7
Q

When would Light’s criteria be used

A

If the pleural fluid protein is between 25 and 35 g/L

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8
Q

What is the pathophysiology behind an exudative pleural effusion?

A

Inflammation –> results in protein leaking out of the tissues into the pleural space due to increased pleural and capillary permeability

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9
Q

What are the most common causes of exudative pleural effusions?

A

1) Infection – pneumonia, tuberculosis

2) Malignancy – bronchial carcinoma, mesothelioma, lung metastases

3) Rheumatoid arthritis (less common)

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10
Q

What is the pathophysiology behind transudative pleural effusions?

A

1) Disruption in hydrostatic pressure → increase in pulmonary hydrostatic pressure forces fluid out of pulmonary capillaries into pleural space

2) Disruption in oncotic pressure → impaired reabsorption of fluid from pleural space into pulmonary capillaries

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11
Q

What are the most common causes of transudative pleural effusions?

A

1) Congestive cardiac failure (most common)

2) Liver failure (most common)

3) Hypoalbuminaemia

4) Hypothyroidism

5) Meig’s syndrome

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12
Q

How does liver failure cause transudative pleurral effusion?

A

Pleural effusion is caused by high pressure in the portal vein (portal hypertension).

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13
Q

How does hypoalbuminemia cause transudative pleural effusion?

A

Hypoalbuminemia can cause a decrease in oncotic pressure causing extravasation of fluid into the interstitial space

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14
Q

What type of pleural effusion does malignancy cause?

A

Exudative

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15
Q

What type of pleural effusion does infection cause?

A

Exudative

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16
Q

What type of pleural effusion does liver failure cause?

A

Transudative

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17
Q

Give 3 other types of pleural effusion

A

1) Haemothorax –> blood in the pleural space

2) Empyema –> pus

3) Chylothorax –> chyle

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18
Q

What causes a chylothorax?

A

Chyle in the pleural space due to disruption of the thoracic duct (due to a neoplasm, trauma or infection/inflammation)

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19
Q

What is Meig’s syndrome? What is the triad of features?

A

1) Benign ovarian tumour (typically a fibroma)

2) Pleural effusion

3) Ascites

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20
Q

Management of Meig’s syndrome

A

The pleural effusion and ascites resolve with the removal of the tumour.

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21
Q

Would nephrotic syndrome cause a transudative or exudative pleural effusion?

A

Transudative

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22
Q

Would hypoalbuminaemia cause a transudative or exudative pleural effusion?

A

Transudative

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23
Q

Disruption of which structure leads to a chylothorax?

A

Thoracic duct

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24
Q

Typical symptoms of a pleural effusion?

A

Small and moderate pleural effusions are commonly asymptomatic. As the pleural effusion increases in size, symptoms begin to develop.

  • Shortness of breath (typical presenting symptom)
  • Cough
  • Pleuritic chest pain
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25
Q

Typical examination findings in pleural effusion?

A
  • ‘Stony dull’ percussion over effusion
  • Reduced breath sounds
  • Tracheal deviation AWAY from the effusion in very large effusions
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26
Q

Important areas to cover in a pleural effusion history?

A
  • Symptoms suggestive of LUNG CANCER: haemoptysis, weight loss
  • Symptoms suggestive of HEART FAILURE: orthopnoea, paroxysmal nocturnal dyspnoea, leg swelling
  • Symptoms suggestive of INFECTION: productive cough, fever
  • Social history: SMOKING history (lung cancer risk), ASBESTOS exposure (mesothelioma)
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27
Q

What respiratory condition can be associated with rheumatoid arthritis?

A

Pleural effusion

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28
Q

Differentials for pleural effusion?

A

Breathlessness, cough and pleuritic chest pain:

  • Infection: such as pneumonia or tuberculosis
  • Malignancy without effusion
  • Pulmonary embolism
  • Pneumothorax
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29
Q

Are transudative or exudative pleural effusions more likely to be bilateral?

A

Transudative

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30
Q

Are transudative or exudative pleural effusions more likely to be unilateral?

A

Exudative

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31
Q

1st line investigation in pleural effusion?

A

CXR

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32
Q

Bedside investigations in pleural effusion?

A
  • ECG –> look for cardiac cause, or signs of right heart strain (PE)
  • Urine dip –> assess for proteinuria (nephrotic syndrome)
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33
Q

Why would a urine dip be indicated in pleural effusion?

A

Assess for proteinuria which may indicate nephrotic syndrome

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34
Q

Potential blood tests in a pleural effusion:

A
  • FBC → may show raised WCC (infection)
  • U&Es → may show raised creatinine (renal impairment)
  • LFTs & coagulation profile → may show low albumin and raised ALT/AST (cirrhosis)
  • CRP → infection
  • Blood cultures → infection
  • ABG → if oxygenation affected
  • D-dimer → if PE suspected
  • Amylase → if pancreatitis suspected
  • TFTs → if hyperthyroidism suspected
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35
Q

What are some potential CXR findings in a pleural effusion?

A

1) Blunting of the costophrenic angle

2) Fluid in the lung fissures

3) Larger effusions will have a meniscus (a curving upwards where it meets the chest wall and mediastinum)

4) Tracheal and mediastinal deviation away from the effusion in very large effusions

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36
Q

In smaller pleural effusions, which imaging investigations may be better?

A

US or CT

37
Q

Management of a pleural effusion?

A

If unilateral is thought to be exudative –> pleural fluid analysis (take sample by aspiration or chest drain –> protein count, LDH, pH etc)

If small –> conservative

If bigger:
a) Pleural aspiration
b) Chest drain

Then treat underlying cause:
- Diuretics in HF
- Abx in infection

38
Q

Are pleural aspirations routinely carried out for bilateral effusions with features suggestive of a transudate?

A

No

39
Q

What is pleural aspiration?

A

Involves sticking a needle through the chest wall into the effusion and aspirating the fluid.

Aspiration can temporarily relieve the pressure, but the effusion may recur, and further drainage may be required.

40
Q

Benefit of chest drain over pleural aspiration in pleural effusion?

A

Chest drain can be used to drain the effusion and prevent it from recurring.

41
Q

What should be analysed about the pleural fluid in a pleural effusion?

A
  • Protein
  • LDH
  • Appearance (purulent, bloody)
  • pH (if not purulent)
  • Glucose
42
Q

What can bloody pleural fluid indicate?

A

infection, bloody fluid may suggest malignancy, pulmonary embolism or trauma.

43
Q

What can a pleural fluid pH < 7.3 indicate?

A

Malignancy, pleural infection, rheumatoid arthritis, tuberculosis and oesophageal rupture

44
Q

If the pleural effusion reaccumulates, what can be considered?

A
  • Long term indwelling chest drain
  • Pleurodesis (by chest drain or medical thoracoscopy)
45
Q

Complications of a pleural effusion?

A
  • Respiratory compromise.
  • In parapneumonic effusions, complications may include empyema and sepsi
  • Pneumothoraces (related to pleural procedures)
46
Q

Pleural aspiration results in an empyema?

A

-pus
- low pH
- low glucose
- high LDH

47
Q

management of an empyema?

A

Chest drain & Abx

48
Q

Thoracentesis is indicated in all patients except who?

A

Required in all patients except those with clear evidence of HF (raised JVP, pitting ankle oedema, signs on CXR)

49
Q

What is interstitial lung disease (ILD)?

A

An umbrella term for a broad spectrum of conditions affecting the lung interstitium, leading to INFLAMMATION and FIBROSIS.

50
Q

What is the lung interstitium?

A

the space between an alveolus and its surrounding capillaries.

51
Q

What is fibrosis in the lung?

A

Fibrosis involves the replacement of elastic and functional lung tissue with non-functional scar tissue.

This is irreversible.

52
Q

What is the most important ILD to remember?

A

Idiopathic pulmonary fibrosis

53
Q

Key presenting features of pulmonary fibrosis?

A
  • Shortness of breath on exertion (progressive)
  • Dry cough
  • Fatigue

Examination findings:
- Bibasal fine end-inspiratory crackles
- Finger clubbing

54
Q

Describe auscultation sounds in pulmonary fibrosis

A

Bibasal fine end-inspiratory crackles

55
Q

Risk factors for ILD?

A
  • Male sex
  • Cigarette smoking
  • Regular dust exposure (could be occupational)
56
Q

Important aspects to cover in ILD history?

A
  • Drug history –> Can be caused by some medications, inhaled illicit substances
  • Smoking history
  • Occupation
  • Social history –> mould, pets, hobbies (e.g. bird-keeping)
57
Q

What are some susceptible occupations for ILD?

A

1) farmers (hay dust and Aspergillus mould)
2) bakers (flour dust and additive enzymes)
3) plumbers/construction worker

58
Q

How is ILD/PF diagnosed?

A

1) Clinical features

2) High-resolution CT scan (HRCT) of the thorax (showing a typical “ground glass” appearance)

3) Spirometry

59
Q

Spirometry results in ILD?

A

1) FEV1 and FVC are equally reduced
2) FEV1:FVC ratio greater than 70%

60
Q

Managmement of ILD?

A

Generally, there is a poor prognosis and limited management options in interstitial lung disease, and treatment is primarily supportive. Options include:

  • Remove or treat the underlying cause
  • Home oxygen where there is hypoxia
  • Stop smoking
  • Physiotherapy and pulmonary rehabilitation
  • Pneumococcal and flu vaccine
  • Advanced care planning and palliative care where appropriate
  • Lung transplant is an option, but the risks and benefits need careful consideration
61
Q

What is Idiopathic pulmonary fibrosis?

A

features progressive pulmonary fibrosis with no apparent cause

62
Q

Presentation of pulmonary fibrosis?

A
  • Insidious onset of SOB
  • Dry cough

> 3 months

63
Q

Prognosis of pulmonary fibrosis?

A

The prognosis is poor, with a 2-5 years life expectancy from diagnosis.

64
Q

What 2 medications are licensed that can slow the progression of pulmonary fibrosis

A

1) Pirfenidone –> reduces fibrosis and inflammation

2) Nintedanib –> reduces fibrosis and inflammation by inhibiting tyrosine kinase

65
Q

Give some causes of drug induced pulmonary fibrosis

A

1) Amiodarone
2) Nitrofurantoin
3) Methotrexate

66
Q

What conditions can pulmonary fibrosis occur 2ary to?

A
  • Alpha-1 antitrypsin deficiency
  • Rheumatoid arthritis
  • Systemic lupus erythematosus (SLE)
  • Systemic sclerosis
  • Sarcoidosis
67
Q

What is bronchiectasis?

A

A chronic respiratory disease characterised by permanent bronchial dilation, due to irreversible damage to the bronchial wall.

Sputum collects and organisms grow in the wide tubes, resulting in a chronic cough, continuous sputum production and recurrent infections.

68
Q

What are the bronchi?

A

the large airways that transport air to the lungs

69
Q

Causes of bronchiectasis?

A

Damage to the airways:

  • Idiopathic (no apparent cause - approx 40%)

Post-infectious:
- Pneumonia
- Plmonary TB
- Allergic bronchopulmonary aspergillosis (ABPA)
- Recurrent childhood LRIs e.g. whooping cough (pertussis), influenza

Pulmonary disease:
- Asthma
- COPD

Congenital:
- CF
- Alpha-1-antitrypsin deficiency (also causes emphysema)

-Connective tissue disorders:
- Rheumatoid arthritis
- SLE
- Sarcoidosis

Yellow nail syndrome

70
Q

What triad is seen in yellow nail syndrome?

A

1) yellow fingernails

2) bronchiectasis

3) lympoedema

Patients are stable and have good clinical signs, making it a good choice for OSCEs.

71
Q

Prognosis of bronchiectasis?

A

Patients with mild bronchiectasis often have normal life expectancies. The mortality risk increases in patients with more frequent exacerbations and worse lung function.

72
Q

Risk factors for bronchiectasis?

A

Age (>70 years)
Female gender
Smoking history

73
Q

Are men or women more prone to bronchiectasis?

A

Women

74
Q

Key presenting symptoms in bronchiectasis?

A
  • Shortness of breath on exertion (may progress to resting)
  • Chronic productive cough
  • Recurrent chest infections
  • Weight loss
  • Fatigue
  • Rhinosinusitis symptoms e.g. nasal discharge
75
Q

Is the cough in bronchiectasis dry or productive?

A

Productive

76
Q

Is the cough in pulmonary fibrosis dry or productive?

A

Dry

77
Q

Other important areas to cover in the history in bronchiectasis?

A
  • History of childhood LRTIs –> you may forget to ask this if the patient is elderly
  • Family history –> ask about congenital conditions (such as cystic fibrosis) and autoimmune conditions (such as rheumatoid arthritis)
  • Smoking history: quantify in pack-years
78
Q

Examination findings in bronchiectasis?

A
  • Clubbing
  • Coarse creptiations
  • Rhonchi
  • High pitched inspiratory squeaks and pops
  • Sputum pot by bed
  • Oxygen therapy (if needed)
  • Cachexia
  • Signs of cor pulmonale e.g. raised JVP, peripheral oedema
79
Q

What are rhonchi?

A

Low-pitched noises, which sound like snoring –> caused by the movement of secretions in the large airways

80
Q

What are the 2 most common infective organisms in bronchiectasis?

A

1) Haemophilus influenza

2) Pseudomonas aeruginosa

81
Q

Investigations in bronchiectasis?

A

1) Sputum culture

2) CXR

3) High-resolution CT (HRCT)

4) Lung function tests

5) O2 sats

82
Q

What is the test of choice for establishing a bronchiectasis diagnosis?

A

High-resolution CT (HRCT)

83
Q

What do lung function tests typically show in bronchiectasis?

A

typically show an obstructive pattern (FEV1/FVC ratio < 70%), but may be normal

84
Q

General management of bronchiectasis?

A

Vaccines (e.g., pneumococcal and influenza)

Respiratory physiotherapy to help clear sputum

Pulmonary rehabilitation

Long-term antibiotics (e.g., azithromycin) for frequent exacerbations (e.g., 3 or more per year)

Inhaled colistin for Pseudomonas aeruginosa colonisation

Long-acting bronchodilators may be considered for breathlessness

Long-term oxygen therapy in patients with reduced oxygen saturation

Surgical lung resection may be considered for specific areas of disease

Lung transplant is an option for end-stage disease

85
Q

Management of infective exacerbations in bronchiectasis?

A

1) Sputum culture (before antibiotics)

2) Extended courses of antibiotics, usually 7–14 days

86
Q

What should be done before prescribing Abx in bronchiectasis?

A

Sputum culture

87
Q

What is the he Abx of choice for bronchiectasis exacerbations caused by Pseudomonas aeruginos?

A

Ciprofloxacin

88
Q

Key features to remember for bronchiectasis:

A

1) finger clubbing

2) diagnosis by HRCT

3) Pseudomonas colonisation

4) Extended courses of 7-14 days of antibiotics for exacerbations

89
Q
A

Yr 4 - CCC (54 decks)

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