Summary Book Respiratory Flashcards
Example of inhaled corticosteroid preventer
Flixotide (given BD)
3 examples of inhaled corticosteroid and LABA combo
Symbicort (budesonide/formoterol, BD), Seretide (fluticasone/salmeterol, BD), Breo Ellipta (fluticasone, vilanterol, daily)
Example of LAMA (Long-acting muscarinic receptor antagonists)
Spiriva (tiotropium, given daily)
Example of LAMA/LABA combo
Spiolto daily or Ultibro daily
Clinical signs of pancoast tumour syndrome
Cachectic, clubbing, wasting of small hand muscles, reduced sensation of c8-t1, lymphadenopathy, horners, dullness to percussion.
Causes of pancoast tumour syndrome
lung ca, lymphoma, mets
Causes of trachea deviation - towards or away from lesion
Towards: collapse, lobectomy, pneumonectomy, pulmonary fibrosis . Away: large mass (goitre, mediastinal mass), pleural effusion, tension, pneumothorax
Causes of prolonged and reduced forced expiratory time
COPD and bronchiectasis - prolonged. Restrictive disease - reduced.
Clinical signs of pemberton’s sign (SVC obstruction)
oedema of face / arms with dilated veins, raised JVP, cervical lymphadenopathy
Causes of atypical unilateral and bilateral chest expansion.
Unilateral = effusion, collapse, pneumothorax, consolidation and fibrosis. Bilateral = COPD, ILD, asthma, myasthenia gravis, GBS
Causes of dullness to percussion
lobectomy, pneumonectomy, lung consolidation, pleural effusion, pleural thickening, raised hemidiaphragm
Causes of reduced breath sounds
Airway and bronchial obstruction, large bullae, lobectomy, pneumonectomy, lung consolidation, lung hyperinflation, obesity, pleural effusion, pleural thickening, pneumothorax, raised hemidiaphragm, shallow breathing
5 T’s of mediastinal mass
tumour, thyroid goitre, teratoma, thymoma, thromboembolism
Causes of wheeze - widespread with lower airway cause, widespread with central airway cause and unilateral
Widespread and lower = asthma, bronchitis, bronchiolitis, COPD, CCF, cystic fibrosis. Widespread and central = intra-luminal obstruction (foreign body, mucus plug, vocal cord dysfunction), luminal obstruction (laryngeal or tracheal stenosis, anaphylaxis), extra-luminal obstruction (retrosternal goitre, mediastinal malignancies). Unilateral = bronchiectasis, intra-luminal stenosis, luminal obstruction and extra luminal obstruction.
Causes of crepitations - fine vs coarse
Fine = specific interstitial lung disease subtypes (idiopathic pulmonary fibrosis, asbestosis, non-specific interstitial pneumonitis, connective tissue disease associated interstitial fibrosis), pneumonia (resolving), posture induced crackles. Coarse = bronchiectasis, COPD, CCF, pneumonia (acute).
Lights criteria for transudate
protein <0.5, LDH <2/3 ULN, LDH <0.6 ratio
Causes of transudate pleural effusion
cardiac failure, hypothyroidism, liver failure, nephrotic syndrome
Lights criteria for exudate
protein >0.5, LDH >2/3 ULN, LDH >0.6 ratio
Causes of exudate pleural effusion
Drugs: nitrofurantoin, beta blocker, lupus inducing drugs. Granulomatous disease: sarcoidosis. Infective: pneumonia, tuberculosis. Neoplastic: pleural malignancy (mesothelioma), primary lung carcinoma, metastatic carcinoma. Rheumatological: rheumatoid arthritis, systemic lupus erythematosus. Sub diaphragmatic: pancreatic. Vascular: pulmonary infarction.
Causes of interstitial lung disease with known exposure
Drugs: amiodarone, chemotherapy (bleomycin, cyclophosphamide), methotrexate, nitrofurantoin. Environmental (hypersensitivity pneumonitis): bird, allergen. Occupational (pneumoconiosis): asbestos, silica, beryllium, coal dust. Radiation: intra-thoracic malignancy, radiation therapy.
Causes of interstitial lung disease without known exposure
Connective tissue disease: ankylosing spondylitis, eosinophilic polyangiitis, poly- /dermatomyositis, rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis. Granulomatous Disease: sarcoidosis. Idiopathic Interstitial Pneumonias: idiopathic pulmonary fibrosis and other subtypes (NSIP, COP, DIP, RBILP, AIP, LIP). Miscellaneous Disorders: pulmonary lymphangioleiomyomatosis, pulmonary langerhans cell histiocytosis.
Risk factors for interstitial lung disease
smoking, drugs, connective tissue disease, exposure, asthma
Define usual interstitial pneumonia
A histopathologic and radiologic pattern of interstitial lung disease and hallmark pattern of idiopathic pulmonary fibrosis
Management of interstitial lung disease
- Prevention with vaccines, smoking cessation and pulmonary rehabilitation. 2. For IPF/UIP = treatment is poor + don’t give steroids, Nintedanib (multi TKI - 60% get diarrhoea) and Pirfenidone (anti-tumour growth factor - rash/nausea/vomiting). 3. Treatment of non-specific interstitial pneumonia (systemic sclerosis) - cyclophosphamide/steroids. 4. Lung transplant.
Complications of interstitial lung disease
oxygen dependence, loss of function, pulmonary hypertension, death
Clinical findings for interstitial lung disease
clubbing, fine crepitations, systemic features of connective tissue disease or rheumatoid complications of steroid use
CXR findings of COPD
right sided cardiomegaly
Respiratory function testing findings of COPD
Obstructive spirometry, non-reversible, increased total lung capacity, increased residual capacity, decreased DLCO, obstructive flow-volume loop
ECG of COPD
right axis deviation with possible right ventricular hypertrophy
ECHO of COPD
pulmonary hypertension, possible right ventricular failure
Aetiology of COPD
cigarette smoking (80% - active/passive), indoor biomass fuel, chronic asthma, tuberculosis, alpha-1 antitrypsin deficiency, loeys-dietz syndrome (SMAD 3 gene)
Causes of apical crackles in restrictive lung disease
seronegative spondyloarthropathies, sarcoidosis, silicosis, ABPA, TB, pulmonary Langerhans histiocytosis X
Causes of basal crackles in restrictive lung disease
IPF, asbestosis, connective tissue disease, medications, chronic aspiration
CXR findings for restrictive lung disease
reduced volumes, reticular interstitial opacities
HRCT findings for restrictive lung disease (5 classic IPF changes)
- reticular fibrosis. 2. honeycombing +/- traction bronchiectasis. 3. basal and subpleural predominance. 4. absence of atypical features (ground glass, mosaic attenuation, consolidation). 5. temporal heterogeneity.
Respiratory function tests for restrictive lung disease
FEV1/FVC >70%. FVC <80%. reduced DLCO
Additional tests to consider for restrictive lung disease
VATS for lung biopsy, 6MWT + ABG on room air, TTE to exclude pulmonary hypertension, ABG to investigate hypoxia and T1RF
9 management steps to consider for restrictive lung disease
- remove trigger. 2. smoking cessation. 3. influenzae and pneumococcal vaccination. 4. MDT for IPF medications. 5. management of GORD / rheumatological disease. 6. bronchodilators if reversibility. 7. IPF-specific anti-fibrotic (Nibtedanib and Pirfenidone). 8. Home oxygen (if PaO2 <55 or <60 with pulmonary hypertension). 9. Lung transplant.
Define bronchiectasis
Permanent bronchial dilation due to post-infectious fibrotic changes, resulting in airway obstruction, impaired mucus drainage and abnormal anti-microbial host resposnse
Upper lung zone causes of bronchiectasis
cystic fibrosis and congenital causes, TB, ABPA, autoimmune, connective tissue disorders, chronic hypersensitivity pneumonitis
Middle lung zone causes of bronchiectasis
NTM (nontuberculous mycobacteria), MAC (Mycobacterium avium complex)
Lower lung zone causes of bronchiectasis
chronic recurrent infections or aspiration, end-stage fibrotic lung disease
Central lung zone causes of bronchiectasis
ABPA, congenital, cystic fibrosis
CXR findings for bronchiectasis
coarse parallel tram-track, tubular or ring opacities of dilated bronchi. Also linear atelectasis.
Organisms found in sputum for bronchiectasis
Hemophilus, pseudomonas, pneumococcus, mycobacterium
HRCT findings for bronchiectasis
airways larger in diameter than the blood vessel they run with, distribution and pattern of bronchiectasis, presence of concomitant infections / effusions / mass lesions
Pulmonary function tests for bronchiectasis
obstructive spirometry, possible gas trapping and hyperexpansion, decreased DLCO
Tests for cystic fibrosis
chloride sweat test, exercise capacity, 6MWT
10 Management steps to consider for bronchiectasis
- reduce inflammation with physiotherapy and postural drainage (twice daily). 2. control infections / vaccinations / smoking cessation. 3. low dose inhaled corticosteroids if reversibility. 4. azithromycin prophylaxis. 5. bronchodilators. 6. pulmonary rehabilitation. 7. bronchial artery embolization - massive haemoptysis. 8. home oxygen if FEV1 <40%. 9. Transplant. 10. IVIG - hypogammaglobulinemia
Symptoms of bronchiectasis
haemoptysis, purulent sputum, fevers, dyspnoea, weight loss, possible right heart failure
Risk factors for bronchiectasis
childhood respiratory disease, chronic lung infections (TB, influenza, adenovirus), COPD, cystic fibrosis, allergic bronchopulmonary aspergillosis, rheumatoid, sjogrens, immunodeficiency (hypogammaglobulinemia)
Signs of bronchiectasis
respiratory distress, cachexia, signs of right heart failure, reduced breath sounds, wheeze, crepitations, sputum, dextrocardia (kartagener syndrome)
Define reversibility
> 12% and 200ml in either FVC or FEV1
Define DLCO and what decreases it, increases it or doesn’t change it
DLCO is indicative of gas exchange (alveolar-capillary interference) dysfunction. Decreases with COPD, ILD, pulmonary hypertension and anaemia. If DLCO is the only parameter to change then consider PE or ILD. DLCO increases with haemorrhage. Normal in asthma, neuromuscular disease, chest wall disorder and obesity.
Signs of lung transplant.
Transplant scar - single (lateral thoracotomy) or bilateral (clamshell). If single then remaining lung may be IPF with abnormal expansion and auscultation. Also check for pulmonary hypertension, right heart failure and side effects of immunosuppression.
Side effects of immunosuppression
tremor with tacrolimus, hirsutism with cyclosporin, diabetes, cushingoid, osteoporosis (scoliosis / thoracic kyphosis), skin cancers and gout (polyarthritis or tophi)
5 aspects to monitor in transplantation
rejection, infection, immunosuppressant side effects, primary disease recurrence and for lung - bronchiolitis obliterans (secondary to chronic infections causing small airway obstruction)
What to check for in rejection in lung transplant
check FEV1, transbronchial biopsy, ?requires pulse of steroids
What to check for with infections in lung transplant
most common cause of death, needs 3 months of prophylactic agents. Organisms = CMV, adenovirus, influenzae and fungal.
What to check for with immunosuppressant side effects in lung transplant
AKI, hypertension, hyperlipidaemia, osteoporosis, neuropathy, cancer
What to check for with recurrence in lung transplant
sarcoid and ILD
Prophylactic measures in lung transplant
vaccines, DEXA 5 yearly, skin check, mammogram 2 yearly between 50 and 74, FOBT + PSA 2 yearly between 50 and 74, cervical screening 5 yearly (25 to 74)
5 indications for lung transplant
- severe COPD - FEV1 <25%, pCO2 >55mmHg. 2. cystic fibrosis with bronchiectasis - FEV1 <30%. 3. ILD with progressive symptoms and DLCO <60%. 4. Pulmonary hypertension with new york heart association 3 or 4. 5. Eisenmenger syndrome.
What is triple drug maintenance?
- Calcineurin inhibitor (cyclosporin or tacrolimus). 2. Anti-proliferates (azathioprine or mycophenolate). 3. Corticosteroid (prednisolone).
Side effects of corticosteroids
myopathy, infection, cataracts, hypertension, diabetes, osteoporosis, gastritis, mood
Side effects of tacrolimus
CNS, hypertension, renal impairment, infection, skin cancer, alopecia, lipids, TMA (thrombotic microangiopathy), tremor, diabetes, CMV, BK
Side effects of everolimus
hypertension, upset GIT, marrow suppression, pulmonary fibrosis, lipids, albuminuria, poor healing, effusions (cardio and resp)
Side effects of cyclosporin A
hypertension, gout, gum hypertrophy, hirsutism, high cholesterol, renal impairment, neurotoxicity
Side effects of mycophenolate
diarrhoea, marrow suppression
Side effects of azathioprine
hepato and marrow toxicity, pancreatitis
Presentation of cystic fibrosis
failure to thrive, recurrent respiratory tract infections - age of diagnosis 4 to 6 weeks. Also cough, sputum, haemoptysis, wheeze, dyspnoea, sinusitis, steatorrhea, diabetes, infertility, biliary cirrhosis.
Risk factor for cystic fibrosis
Family history (autosomal recessive)
Investigations for cystic fibrosis
Diagnosis - sweat test, CXR - progressive increase lung markings / acute consolidation, sputum culture - H. influenzae, pseudomonas, staph, blood - anaemia, vitamin malabsorption, LFT. Spirometry.
Management of cystic fibrosis
Respiratory - postural drainage, prophylactic antibiotics (azithromycin, nebulised aminoglycosides), DNA mucolytic, vaccinations, lung transplant work up. Gut - insulin, creon, vit ADEK, PPI. Infertility specialist. Ivacaftor = increases activity of CFTR protein. Lumacaftor = improves protein folding of CFTR protein. Both Ivacaftor and Lumacaftor for F508 del type.
Complications associated with cystic fibrosis
Recurrent LRTI, pancreatic insufficiency, pneumothorax, pulmonary hypertension, infertility, biliary cirrhosis. Salt crisis due to exercise or dehydration. Poor prognosis if low FEV1 / recurrent admissions / haemoptysis. Social support issues.
Signs of cystic fibrosis
Malnourished, loose cough, nail clubbing, resp. sounds, right heart failure / pulmonary hypertension, organomegaly.
Causes of lung lesions by radiologic appearance - reticular, cavitating, calcified, coin lesion.
Reticular - ILD / IPF. cavitating - abscess / cancer / TB / aspergillus. calcified - TB / pneumoconiosis. coin lesion - cancer / TB / rheumatoid nodules / hydatid cyst / haematoma / AV fistula.
Differential for causes of fatigue
lack of sleep, medications, narcolepsy, depression, restless legs syndrome, anaemia, low thyroid
Presentation and risk factors for OSA
Presentation - daytime fatigue, apnoea, tonsillar surgery, history of CCF / COPD. Risk factors - obesity , hypertension, alcohol, sedating medications, large tonsils.
Investigations and examination tools for OSA
Sleep study, thyroid function, ECHO (pulmonary hypertension), STOP BANG, Epworth
Management of OSA
CPAP and surgery
Complications of OSA
IHD, CVA, MVA, hypertension, pulmonary hypertension, lethargy
Presentation and risk factors of lung cancer
Haemoptysis, weight loss, pleural effusion, ECOG. Risk factors = smoking, radiation, occupational exposure, TB/ILD/scleroderma.
Investigations for lung cancer
CT / PET - peripheral = adenocarcinoma or large cell, central = squamous or SCLC. Biopsy. Type and staging - TNM for NSCLC, limited or extensive for SCLC.
Associations for lung adenocarcinoma
non-smoker, female, do EGFR mutation test
Associations for squamous lung cancer
smoker, intrathoracic spread
Associations for SCLC
strongest assoc. with smoking, neuroendocrine, paraneoplastic, distant metastasis
Management for lung cancer
Surgery for stage 1 to 3a (plus chemo rad) - need to climb 3 stairs or FEV1 >1.5L. Chemotherapy (etoposide + cisplatin) +/- immunotherapy +/- radiotherapy. Average 5 year survival is 15%.
Examination findings for lung cancer
clubbing, fixed expiratory wheeze, Pancoast tumour, recurrent laryngeal palsy, lymphadenopathy
Tests and management of IgE asthma
Omalizumab (anti-IgE). Test - IgE, skin prick test, atopic features.
Tests and management of eosinophil asthma
Mepolizumab (anti-IL5). Test - eosinophils / FENO.
Escalating bronchodilators for COPD
- SABA PRN. 2. LAMA +/- LABA. 3. LAMA / LABA or LABA/ICS if also asthma. 4. Triple therapy
Examination findings for COPD
respiratory distress, hypoxia, cachexia, decreased air entry, wheeze, crepitation, sputum, right heart failure
Complications of COPD
hospital/ICU admissions, LRTI, ventilator support, steroid use, functional decline
Severity of FEV1 by percentages
FEV1. >80% mild, >50% moderate, >30% severe, <30% very severe.
Presentation and risk factors of COPD
cough, sputum, dyspnoea, wheeze, weight loss. Risk factors = smoking, occupational exposure, exacerbating factors.
Investigations for COPD
spirometry with FEV1/FVC <0.7 + imaging
Acute management of exac of COPD
assess severity with 6MWT and ABG, bronchodilators, steroids, IV Abx, BiPAP, septic screen, assess for right heart strain (TWI in 2,3,V1-4) and right axis deviation
Preventative measures for COPD
stop smoking, management plan, preventative inhalers (asses technique), pulmonary rehab, vaccinations, antibiotics for infections, home oxygen (sat <88%, pO2 <55%), lung volume reduction surgery
