Short Case Respiratory Xpress Flashcards
State the causes of lung collapse
- Bronchogenic CA
- TB
- Bronchial adenoma
State the causes of lung consolidation
- Bacterial pneumonia
- Bronchogenic CA
- Pulmonary infarct
State (2) causes of bibasal crackles with finger clubbing
- Bronchiectasis
- Interstitial lung disease
State (2) causes of bibasal crackles without finger clubbing
- Left ventricular failure
- Bronchopneumonia
Define asthma
- Chronic inflammatory disorder of the airway characterized by bronchial hyper-responsiveness of the airway to various stimuli, leading to widespread bronchocontriction
How would you diagnose bronchial asthma?
- Typical symptoms/signs
- Lung function test
- > 20% of diurnal variation in PEF on >3 days in a week for 2 weeks
- FEV1 >15% increase after bronchodilator or oral steroid
- FEV1 >15% decrease after 6 minutes of exercise (running)
What are the indicators of severe asthma?
- Inability to complete 1 sentence in 1 breath
- RR >25/min
- Pulse rate >110/min
- PEF <50% of predicted or best value
What are the indicators of life-threatening asthma?
- Exhaustion, confusion, coma
- Bradycardia, hypotension
- Silent chest, cyanosis
- PEF <33% of predicted or best value
- Normal or increased PCO2
- PO2 <60mmHg
How do you manage a case of acute asthma?
- ABG
- CXR (to exclude pneumothorax)
- O2, nebuliser - Beta-agonist
- High dose steroid (IV hydrocortisone, prednisolone)
- For severe attack -> IV aminophylline, consider ventilation
Define COAD
A disease state characterized by AIRFLOW LIMITATION that is not fully reversible
How do you diagnose a case of COAD?
Key indicators:
- Chronic cough with sputum production
- Progressive or persistent dyspnea
- History of smoking
- Exposure to occupational dusts or chemicals
Spirometry (To confirm the diagnosis of COAD)
- Airflow limitation (FEV1/FVC <70%) that is not fully reversible (post-bronchodilator FEV1 <80% of predicted value)
What does finger clubbing in COAD superimposed?
Superimposed BRONCHOGENIC CA, chronic infection
Finger clubbing is NOT a feature of COAD
State (2) differentials for COAD
- Left ventricular failure
- Chronic asthma
What are the additional investigations of COAD?
- Bronchodilator reversibility test (Largely irreversible in COAD)
- Glucocorticoid reversibility test (>15% increase in FEV1 after a course of steroid therapy)
- Chest X-ray (Hyper-inflation, bullous changes, pulmonary hypertension)
- ECG (Cor pulmonale -> Peaked P wave at L2, 3 and AVF)
- ABG
- Alpha-1-antitrypsin deficiency (indicated in young patients <45Y or those with strong family history of COAD)
How would you manage a case of acute exacerbation of COAD?
- Nebulized bronchodilator, oxygen
- CXR -> to exclude pneumothorax
- Antibiotics (H. influenza, Strep pneumonia)
- Steroids (Oral or IV)
What are the possible findings on PE in a patient with COAD?
- Face
- Chest
- Abdomen
Face
- Central cyanosis
- Polycythemia
- Pursed lips
Chest
- Barrel chest
- Hyper-resonance
- Downward displacement of upper border of liver
- Rhonchi
- Loud S2 (Pulmonary hypertension)
Abdomen
- Palpable liver
Possible cause:
1. Hyper-inflated lungs
2. Bronchogenic CA with liver metastasis
3. Cor-pulmonale
State the clinical features of bronchogenic CA
- Primary tumor - Pancoast syndrome
- Mediastinal spread - hoarseness (recurrent laryngeal nerve palsy), superior vena cava obstruction
- Metastasis - pleura, liver, brain, adrenal
- Paraneoplastic syndrome (PNS)
1. Endocrine - ectopic ACTH secretion (scc), gynecomastia (adc), syndrome of inappropriate ADH secretion/SIADH (scc), hypercalcemia (sqcc)
2. Neurological - cerebellar syndrome, poly-/dermatomyositis, LEMS
3. Others - hypertrophic pulmonary osteoarthropathy, clubbing
What are the investigations to be done for a case of bronchogenic CA?
- Serum sodium, calcium
- CXR - hilar mass or coin lesion, rib erosions, raised hemidiaphragm (phrenic nerve paralysis), lymphangitis carcinomatosis
- Pleural fluid cytology
- Bronchoscopy (+ washing and brushing) - endobronchial tumor
- CT scan thorax/abdomen, bone scan - staging
- Lung function test - FEV1
Define Pancoast syndrome
Apical lung tumor with
- Invasion of lower trunk (C8 - T1) of brachial plexus -> WASTING OF SMALL MUSCLES OF THE HAND
- Sympathetic chain -> HORNER’S SYNDROME
- 2nd-3rd ribs
Define interstitial lung disease
- A.k.a diffuse parenchymal lung disease
- Group of disorders that involve the space between epithelial and endothelial basement membrane
State the causes of ILD
- Known cause
1. Drugs
2. Connective tissue disease
3. Occupational exposure - asbestos, silica - Idiopathic pulmonary fibrosis
- Granulomatous DPLD - Sarcoidosis
- Other forms of DPLD
What are the investigations of ILD?
- CXR
- Lung function test
- CTD screen
- High-resolution CT (HRCT)
- Bronchial lavage
- Lung biopsy
What is the possible treatment for ILD?
- Steroid/cyclophosphamide
- Treat underlying cause
Define bronchiectasis
Chronic suppurative inflammation of the bronchi that results in permanent dilatation of the airways
State the etiologies of bronchiectasis
- Post-infectious (Measles, Pertussis, TB, aspergillosis)
- Endobronchial obstruction (Bronchial adenoma/carcinoma)
- Congenital - Kartagener’s syndrome, hypogammaglobulinemia (extremely rare)
What are the complications of bronchiectasis?
- Pneumonia
- Hemoptysis
- Cerebral abscess
- Amyloidosis
What investigations to be done to diagnose a case of bronchiectasis?
- Sputum AFB/fungal culture
- Sputum culture - H influenza, P aeruginosa, Strep pneumonia
- CXR - ring-like shadows , tram lines, focal opacities
- Aspergillus precipitin test
- High-resolution CT
1. BEST tool to diagnose
2. Detects airway changes that are not visible on X-ray
List the specific treatment of bronchiectasis
- Bronchopulmonary hygiene
- Antibiotics
- Surgical resection of damaged segments/lobes that are nidus for infection
In diagnostic approach to pleural effusion, what are the (2) important questions?
- Is the fluid a transudate or exudate?
- If the fluid is an exudate, what is the etiology?
What are the investigations to be done for pleural effusion and the possible findings?
CXR/US/CT scan
- Helps in finding the best site for pleural tap
Pleural tap and fluid analysis
- Protein
- Glucose (Decrease in infection and malignancy)
- Gram stain, Ziehl-Neelson stain
- Culture/cytology
- Adenosine deaminase (Increase in tuberculous effusion)
Percutaneous pleural biopsy
- Indicated in undiagnosed pleural exudates with non-diagnostic cytology and clinical suspicion of TB or malignancy
State the laboratory findings of a transudate and its possible cause
- Protein <30g/l
- LDH <200IU/L
- Pleural : serum LDH ratio <0.6
Possible cause
- Cardiac failure
- Nephrotic syndrome
- Chronic liver disease
State the laboratory findings of an exudate and its possible cause
- Protein >30g/l
- LDH >200IU/L
- Pleural : serum LDH ratio > 0.6
Possible cause
- Malignancy
- Pneumonia
- TB
- Pulmonary infection
- Connective tissue disease
State the laboratory findings of an empyema and its possible cause
- Turbid, foul-smelling
- Centrifuged pleural fluid - clear supernatant
Possible cause
- Lung infection
- Chest trauma
- Thoracic surgery
- Subdiaphragmatic abscess
