Respiratory shorts Flashcards
Pulmonary function tests
- FEV1/FVC ratio (FER) < 0.7 = obstruction
- FVC < LLN (70%) = restriction -> TLC (<80%)to confirm
- FEV1 = severity (<70% mod <40% severe)
- TLCO (diffusion capacity) ie parenchymal or vascular issue (ILD, pulmonary vascular deficit)
. <40% severe (76-140% normal) - VA (alveolar volume)
- KCO (TLCO/VA)
. If normal with low VA = lobectomy / pneumonectomy
. If low with normal VA = parenchyma / vascular
Respiratory exam
GEN INSP
-respiration (increased, accessory muscle use)
-supplemental O2
-pallor / plethoric
-sputum mug
-cough (dry / loose / productive)
-voice: hoarseness (recurrent laryngeal nerve palsy)
HAND DANCE:
-fine tremor (look at nails)
-flapping tremor (look at palm)
-proximal myopathy
-pembertons (look at face, neck)
HANDS
-clubbing
-nicotine staining
-peripheral cyanosis
-wasting/weakness (finger muscles)
-wrist tenderness
-asterixis (CO2 narcosis)
VITAL signs: RR, HR
ARMS
-proximal myopathy
FACE
-eyes: horner’s (apical tumor), jaundice, anaemia
-mouth: central cyanosis
NECK
-trachea (midline / displaced +/- tracheal tug)
-masses (cervical/supraclavicular/axillary lymphadenopathy)
CHEST POSTERIOR / ANT
1. INSPECT
-deformity: kyphoscoliosis, pectus carinatum or excavatum
-scars: surgical, radiotherapy
-prominent veins (direction of flow)
2. PALPATE
-cervical lymph nodes
-expansion
3. PERCUSS (supraclavicular, back, axilla)
4. AUSCULTATE
FORCED EXP TIME
CARDIO:
-JVP: SVC obstruction), pembertons
-Apex beat
-Pulmonary HTN
-Cor pulmonale
OTHER:
-sputum cup
-temperature, O2 sats
-peak flow meter
-examine for other malignancy (breast, abdo, rectum, lymph nodes)
-fundi (CO2 narcosis)
Interstitial pulmonary fibrosis:
Fine insp crackles in lower zones bilaterally
Dyspnoea, cyanosis, clubbing
Reduced chest expansion
Dull percusion
Upper and Lower lobe fibrosis
SCART
RASIO
Ix:
ABG, PFT, CXR, HRCT
6MWT
UIP = basal predominance, subpleural reticulation, honeycombing, traction bronchiectasis.
NSIP = groundglass changes + above.
Mx: anti-fibrotic agents (nintedanib, perfenidone)
-pulm HTN with sildenafil
-lung rehab
-lung transplant
UPPER LOBE:
Sarcoid/silicosis
Coal workers pneumoconiosis
Ank spon, allergic bronchopulmonary aspergillosis
Radiation
Tuberculosis
LOWER LOBE:
Rheumatoid
Asbestos, A1AT def, Aspiration
Scleroderma/SLE
Idiopathic pulmonary fibrosis
Others (bleomycin, amiodarone, BOOP)
Bronchiectasis:
Coarse late insp crackles lower zones bilaterally
Heavy purulent sputum
Kyphosis/chest wall deformity
Clubbing
Sinus tenderness
+/- situs inversus
Other: temp chart (pneumonia), sputum cup (haemoptysis)
Ix: FBC, CXR (cystic opacities with air fluid level, tram tracking bronchioles, ring like opacities), HRCT (airway dilation, cysts), bronchoscopy
UL = CF, ABPA
Middle lobe = MAC
Other complications:
-brain abscess
-amyloidosis
Causes
-Post-infectious
-Immunodeficiency
-Mucociliary dyskinesia
-Obstruction
Mnemonic: A SICK AIRWAY
Causes:
Post-infectious- recurrent pneumonia, TB, measles, bronchopulmonary aspergillosis
Immunodeficiency- hypogammaglobulinemia
Mucociliary dyskinesia- primary ciliary dysfunction (kartageners), cystic fibrosis
Obstruction- airway lesion, chronic obstruction
A SICK AIRWAY
Airway lesion, chronic obstruction
Sequestration (congenital, non-functioning piece of lung)
Infection, inflammation
Cystic fibrosis
Kartageners syndrome
Allergic bronchopulmonary aspergillosis
Immunodeficiency (hypogammaglobulinemia, myeloma, lymphoma), inhalation injury
Reflux
William campbell syndrome (deficient cartilage formation and distal airway collapse) ?other congenitals
Aspiration
Yellow nail syndrome (1. yellow hard nails 2. lymphedema 3. respiratory dx) / young syndrome (genetic: sinusitis, otitis media, infertility, pulmonary).
Lobectomy
-thoracotomy scar
-tracheal deviation (towards side - upper lobectomy or pneumonectomy)
-reduced chest expansion unilateral
-dull percussion note (fluid filled) or resonant (air)
-reduced breath sounds or overlying bronchial breath
-displaced apex beat
Indication for lobectomy
- TAMI
Indication for lobectomy:
Trauma
Airways disease (COPD with bullae, bronchiectasis with haemoptysis)
Malignancy
Infection (bacterial, mycobacterium, mycotic e.g. aspergilloma, TB)
Indication for thoracotomy scar (5)
Indication for thoracotomy scar:
Lobectomy or pneumonectomy
Lung volume reduction or bullectomy
Open lung biopsy
Cardiac (right anterolateral for minimally invasive cardiac surgery)
Other (esophageal surgery)
Indication for VATS (video assisted thoracic surgery):
Lobectomy and pneumonectomy
Lung volume reduction or bullectomy (emphysema)
Wedge resection
Lung parenchymal biopsy
Spontaneous primary pneumothorax (correction)
Pleurodesis
Pneumothorax
-tracheal deviation (away if tension, toward if large)
-reduced chest expansion unilateral with hyperresonant percussion, reduced breath sounds and decreased vocal resonance
Causes
Pneumothorax management
Causes:
-spontaneous
-marfans
-traumatic
-emphysema related
Pneumothorax management:
Primary spontaneous <2cm observation
. Needle aspirate if >2cm, symptomatic or haemodynamic compromise.
Secondary pneumothorax
. <2cm hiflow and observe
. >2cm needle aspirate
VATS
Pleural effusion:
-aspiration marks
-tracheal deviation away
-ipsilateral reduced chest expansion, dull to percuss (stony), reduced breath sounds and vocal resonance
Fluid analysis:
-Protein, albumin, LDH, pH, glucose
-MCS
Causes of pleural effusion:
-Lights criteria
-Exudate
-Transudate
Causes of pleural effusion:
Lights criteria (EXUDATE)
- pleural-serum protein >0.5
- pleural-serum LDH >0.6
- pleural LDH > 2/3 upper limit of normal
EXUDATE DDX
-infection: pneumonia, tuberculosis, subphrenic abscess
-malignancy: lung cancer, metastatic, mesothelioma
-infiltrative: sarcoidosis
-vascular: pulmonary infarct
-gastrointestinal: pancreatitis,
-CTD: RA, SLE
-drugs: nitrofurantoin (acute), MTX, amiodarone, cyclophosphamide, dantrolene, isotretinoin, propylthiouracil, ACEI, drugs causing lupus (MSHIPPE), bromocriptine
-radiation
TRANSUDATE DDX
-heart failure
-nephrotic syndrome
-liver failure
-meig’s syndrome (ovarian fibroma and pleural effusion)
-hypothyroidism (clasically exudate)
Causes of clubbing
1. reduced chest expansion, fine bibasal creps = pulm fibrosis
2. reduced chest expansion, coarse bibasal creps, moist cough = bronchiectasis.
Respiratory
Cardiac
GI
Other
Respiratory: bronchogenic carcinoma, mesothelioma, IPF, lung abscess, empyema, bronchiectasis (cystic fibrosis)
Cardiac - IE, cyanotic congenital heart disease
Gastrointestinal- cirrhosis, inflammatory bowel disease (UC)
Other- thyrotoxicosis, familial
Pleural fluid analysis
pH <7.2
Glucose <3.3
RBC >5000
Amylase >2000
Complement decreased
Chylous
pH <7.2
-empyema
-TB
-neoplasm
-RA
-esophageal rupture
Glucose <3.3
-infection
-carcinoma/mesothelioma
-RA
RBC >5000
-pulmonary infarct
-neoplasm
-trauma
-asbestosis
-TB
-pancreatitis
Amylase >2000
-pancreatitis
-abdo viscera rupture
-esophageal rupture
Complement decreased
-RA
-SLE
Chylous
-tumor (lymphoma)
-thoracic duct trauma
-TB
-tuberous sclerosis
BREATH SOUNDS
Vesicular
Bronchial
Reduced
Wheezes
Crackles
Vesicular (normal)
Bronchial (exp prolonged, blowing, normal for upper airways)
-lobar pneumonia
-localised fibrosis or collapse
-above pleural effusion
-large lung cavity
Reduced (instead of “air entry”)
-emphysema
-large lung mass
-collapse, fibrosis or pneumonia
-effusion
-pneumothorax
Wheezes
-insp: asthma, upper airway extrathoracic obstruction
-exp: asthma and copd
-fixed insp wheeze
. monophonic: no change with respiration
. fixed bronchial obstruction
. carcinoma
Crackles
-late or pan inspiratory
. fine, dry - fibrosis
. medium- LV failure
. coarse- bronchiectasis or retained secretions
-early inspiratory (COPD, coarse)
CXR interpretation
-homogenous opacity
-localised non-homogenous
-diffuse
-reticular (linear)
-cavitated lesions
-calcified lesions
-miliary calcification
-coin lesion
-homogenous opacity
. pneumonia (lobar or segmental)
. collapse
. effusion
-localised non-homogenous
. pneumonia
. pulmonary infarct
. carcinoma
. tuberculosis
-diffuse
.TB
.mets
.sarcoid
.pneumoconiosis
.lymphoma
.lymphangitis
.viral pneumonia
.vasculitis (PAN, GPA)
.pulmonary haemorrhage
-reticular (linear)
. fibrosis
. bronchiectasis
-cavitated lesions
. lung abscess
. fungi (coccidioidomycosis)
. hodgkin lymphoma
. TB
. carcinoma (squamous)
-calcified lesions
. TB
. pneumoconiosis
. post-chicken pox pneumonia
. tularaemia (rabbit fever)
-miliary calcification
. post-chicken pox pneumonia
. histoplasmosis
. coccidiodomycosis
. ectopic calcification of CKD, hyperparathyroidism
-coin lesion
. carcinoma (primary or metastatic look for rib lesions)
. TB
. hamartoma
. granuloma (fungus)
. AV fistula
. rheumatoid nodule
. lung abscess
. hydatid cyst
Lung transplant examination
Clam shell scar
A. Aetiology
Other lung if unilateral transplant.
Clubbing - bronchiectasis, lung cancer, ILD
Nicotene staining - COPD, lung ca
CTD - arthritis, skin thickening, skin changes (dermatomyositis)
Cystic fibrosis
B. Complications of immunosuppression.
Cushingoid features
-large body habitus
-face: moon facies, facial plethora
-gynaecomastia
-proximal myopathy
-fluid retention
-abdo distension with striae
Calcineurin inhibitor toxicity
-fine tremor
-gingival hypertrophy
-nephrotoxocity
-HTN
Skin cancer scars.
Cytopenias/infection risk.
COPD
FET prolonged >5s
Barrel chest
Bronchodilators present
Reduced breath sounds
Pursed lip breathing
Steroid use
Pancoast tumour:
NSCLC (squamous, adenocarcinoma)
Transthoracic needle biopsy
Atrophy of hand / arm
Horner syndrome
Hoarse voice
Supracalvicular lymphadenopathy and dullness to percussion
Haemoptysis, clubbing, HPOA
