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Resp Flashcards

1
Q

Benefits of VATS procedure over open thoracotomy

A

Video-assisted thoracoscopic surgery - small incision, so reduced pain, wound complications, healing time and length of stay

But for Pleurectomy - greater risk of recurrent pneumothorax in VATS (5%) than open (1%)

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2
Q

indications for lobectomy

A
  •  Lung cancer resection (main) - most commonly NSCLC, in RUL
  •  TB
  •  Aspergilloma (to protect from massive haemorrhage)
  •  Lung abscess
  •  Remember pleurectomy for recurrent pneumothox
  •  and Lung volume reduction surgery i.e. bullectomy
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3
Q

FEV1 for lobectomy to have good outcome

A

Good outcome if FEV1 > 1.5

> 2 for a full pneumonectomy

provided there is no ILD or disability from SOB

If not clearly operable patients should have Sats at rest and Transfer Factor (TLCO) >50

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4
Q

FEV1 for pneumonectomy to have good outcome

A

> 2 for a full pneumonectomy

> 1.5 for lobectomy

provided there is no ILD or disability from SOB

If not clearly operable patients should have Sats at rest and Transfer Factor (TLCO) >50

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5
Q

way to measure prognosis in post op lung resection

A

Stair climbing is practical way

FEV1 and VO2 max < 15ml/kg/min

..VO2max = maximal oxygen utilised during maximal exercise

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6
Q

lung cancer histology

A

Small Cell

NSCLC (80%)
Majority - Squamous & Adeno
Also - Large cell & Neuro endo

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7
Q

Most common lung cancer in non-smokers

A

Adenocarcinoma

This is also most common overall, but in smokers squamous is most common

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8
Q

Asbestos causes which cancers

A

Mesothelioma, but also bronchial carcinoma, laryngeal cancer and ovarian cancer.

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9
Q

Lung cancer with hyponatremia

A

Small cell… Occurs because of ectopic ADH secretion

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10
Q

Mx of lung cancers

A

SCLC is rapidly progressive, often presents late…
So early disease - chemoradiotherapy
Late - often palliative chemo

NCLC - could include curative surgical, +/- adjuvant chemoradio

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11
Q

normal examination findings but scar indicating a VATS

A

Could be
• Wedge resection of solitary pul nodule
• Lung biopsy
• Surgical treatment of non-resolving/recurrent pneumothorax

if RECENT lobectomy, may have deviated trachae and reduced AE

Pneumonectomy will have deviated trachae, absent breath sounds and dull perc

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12
Q

scars on VATS procedure vs open thoracotomy

A

Open thoracotomy -
• 15-20cm on lat chest wall
• may also be chest drain scar

VATS -
• 3 scars in triangle
• 3-6cm lat chest wall
• Sometimes only 2 or 1 scar apparently

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13
Q

What is Transfer Factor (TLCO) used for related to lung cancer management

A

If not clearly operable (i.e. FEV1 >2 for pneumonectomy or >1.5 for lobectomy) then TLCO

IF estimated postoperative TLCO and est postop FEV1 is high then low risk

(it measures how your lungs take up oxygen from the air you breathe)

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14
Q

Resp causes of clubbing

A
  •  Bronchogenic carcinoma (AKA any type/subtype)
  •  ILD (particularly IPF)
  •  Bronchiectasis
  •  Lung abscess/empyema
  •  CF
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15
Q

pneumonectomy vs lobectomy examination findings

A

Pneumonectomy will have deviated trachae, absent breathsounds and dull perc

Lobectomy likely to be normal or possibly reduced

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16
Q

copd inhaler management

A

FIRST
Short acting
• …beta-2 agonists, like salbutamol
• or …muscarinic antagonists, like ipratropium

SECOND
if no asthmatic/steroid responsive features:
Long acting:
• …beta-2 agonists, like salmeterol
• AND …muscarinic antagonists, like tiotroprium

If that fails, or if asthmatic/steroid responsive features, then trial inhaled corticosteroids

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17
Q

indications for VATS

A
  • Lobectomy
  • Wedge resection (i.e. cancer etc)
  • Lung biopsy (i.e. ILD, cancer)
  • Decortication (i.e. in long-standing empyema, pleural thickening, hemothorax, and pleural tumors)
  • Bullectomy (i.e. COPD)
  • Pleurectomy (recerrent pneumothoraxes)
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18
Q

Why is suction not be routinely recommended in chest drain pneumothorax?

A

Rare as risk of re-expansion pulmonary oedema

Consider if persistent air leak…arbitrarily defined as continued bubbling of air through a chest drain after 48 h in situ,,,

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19
Q

Mx of pneumothoraces if no prev history < 50yr and breathless

A

(Primary pneumothorax)
• As SOB → aspirate up to 2.5L
• if <2cm and breathing improved then consider discharge + OP review in 2-4weeks
• If not → Chest drain

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20
Q

Mx of secondary pneumothorax

A
  • Always admit
  • > 2cm OR breathless → chest drain
  • 1-2cm → aspirate
  • <1cm → admit for 24h with O2
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21
Q

Can you differentiate between a lobectomy and other indication of VATS in otherwise normal exam

A
  • IF normal chest exam, Lobectomy is less likely
  • indications for lobectomy are often smoking-related diseases

Lobectomy may have normal chest signs but likely signs related to smoking

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22
Q

Eosinophils in asthma

A

~ 40% of severe asthmatics are diagnosed with Eosinophilic asthma

Don’t respond to steroids as well so treated with MABs

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23
Q

Diurnal variation in Asthma

A

Low peak flow in night/morning

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24
Q

spirometry in asthma vs COPD

A
  • both have obstructive picture (<0.7 = reduced FEV1, preserved FVC)
  • Asthma would improve with bronchodilator (15% impr of FEV1)
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25
Q

asthma management

A

1) SABA
2) Add inhaled steroid if: exacerbations in last 2yr; using salbutamol or symp 3/wk; OR waking one night/wk
3) Trial LABA (Salmeterol) +/- increasing steroid
4) Add leukotriene receptor antagonist; theophylline; slow release β2 agonist tablets
5) Oral Steroids

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26
Q

Obstructive respiratory disease

A
  • Asthma
  • Bronchiectasis
  • COPD
  • Rarer…Obliterative bronchiolitis (fixed airflow obstruction, from viral, polutent, Graft vs host (like lung transplant)
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27
Q

causes of polyphonic wheeze

A

obstructive resp disease

  • COPD
  • Asthma
  • Bronchiectasis
  • Rarer…Obliterative bronchiolitis (fixed airflow obstruction, from viral, polutent, Graft vs host (like lung transplant)
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28
Q

bibasal crepitations

A

• End-inspiratory fine - ILD
• Coarse-inspiratory - Bronchiectasis
with periph oedema and elevated JVP - Congested HF
• Bilat pneumonia

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29
Q

Spirometry findings in ILD

A
  • Restrictive
  • Reduction in both FEV1 and FVC with preserved ratio
  • Reduced TLC and Transfer Factor
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30
Q

antifibrotic therapies for the treatment of idiopathic pulmonary fibrosis

A
  • Pirfenidone
  • and Nintedanib

Considered by tertiary centres if FVC 50-80%

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31
Q

Management of ILD

A

Conservative
• MDT approach - physio - resp nurses for SOB and QOL

Medical
• Mx underlying connective tissue disorder w DMARD
• May respond to steroids if CT shows ground glass
• if IPF and FVC 50-80% then anti-fibrotic agent

Surgical
• Consideration of lung transplantation

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32
Q

What is HRCT

A

high resolution CT without contrast that gives definition to pulmonary parenchyma
e.g. in pulmonary fibrosis or bronchiectasis

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33
Q

Upper Vs lower zone fibrosis

A

ACID causes lower, the rest upper

  • Asbestosis
  • Connective tissue disorders (except ank spond)
  • Idiopathic pulmonary fibrosis / usual Interstitial Pneumonia
  • Drugs…… (Amiodarone, bleomycin, methotrexate).
Upper:
C -Coal worker's pneumoconiosis
H -Histiocytosis/hypersensitivity pneumonitis
A -Ankylosing spondylitis
R - Radiation
T -Tuberculosis
S -Silicosis/sarcoidosis
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34
Q

Causes of Interstitial lung disease (ILD)

A
  • Idiopathic – IPF, or sarcoidosis
  • Occupational – asbestosis or silicosis
  • Hypersensitivity pneumonitis (ABPA, farmer’s)
  • Connective tissue disease – RA, SLE, polymyositis
  • Drug-induced – Amiodarone, Nitro, Methotrexate, radiotherapy
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35
Q

When would you consider antifibrotic therapies in IPF

A

Considered by tertiary centres if FVC 50-80% predicted in idiopathic pulmonary fibrosis to slow disease progression

(pirfenidone and nintedanib)

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36
Q

patient over 50yr with SOBOE, persistent cough

OE bilat fine end inspiratory crackles, finger clubbing

A

Classic hx of idiopathic pulmonary fibrosis

if no signs of connective tissue disease or occupational

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37
Q

Which interstitial lung disease (ILD) carries worst prognosis?

A

Idiopathic pulmonary fibrosis

  •  Median survival is 2-3 years from diagnosis
  •  Only 20-30% survive to 5 years
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38
Q

Poor prognosistic factors for IPF

A

Basically every bad feature…

  • Old age
  • Dyspnoea
  • Low or declining pulmonary function
  • Pulmonary artery HTN
  • Co-existing emphysema
  • Extensive radiographic involvement
  • Low ET
  • Exertional desat
  • Universal interstitial pneumonia (UIP) on histopath
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39
Q

Pt with coarse inspiratory creps and PEG tube

A

?CF

May have a Button Gastrostomy instead
Also may have clubbing
Could have previous Portacath
Classically upper lobe creps +/- exp wheeze

40
Q

what gene transmits CF?

A

CFTR gene on Chromosome 7

… leads to increase salt excretion

41
Q

Can you tell me anything about the cause of cystic fibrosis?

A
  • Auto recessive
  • Mutation in CFTR chr 7

Leading to increased salt excretion, therefore, thicker mucus which will affect:
• respiratory system → bronchiectasis
• digestive tract → pancreatic insufficiency
• reproductive system → in/subfertility

42
Q

Drug management for CF

A
  •  Regular mucolytics nebs
  •  Creon and Fat soluable vitamins
  •  Prophylactic azithro
  •  Vaccines

• Lumacraftor-ivacaftor (Orkambi) if homogenous ΔF508
(50% of patients are homozygous)

43
Q

what bacteria in CF is absolute contraindication to lung transplantation?

A

Burkholderia cenocepacia

non-tuberculous mycobacteria - Mycobacterium abscessus

(carries particularly poor prognosis so is absolute contraindication)

44
Q

CF life expectancy

A

~50% will live past the age of 40

as per NHS website

45
Q

How is CF diagnosed?

A

All infants in UK are screened using Guthrie’s test for phenylketonuria a few days after birth

Previously, diagnosed following meconium ileus in infancy or failure to thrive

46
Q

CFTR modulating therapies in CF

A

Lumacraftor-ivacaftor (Orkambi) can be used if homogenous delta F508
(50% of patients are homozygous)

47
Q

commonest indications for lung transplant

A

COPD (most common, likely single lung)
Bronchiectasis (including CF)
Pulmonary fibrosis (likely single)
Pulmonary hypertension (may need heart-lung transplant)

48
Q

Double lung transplant vs single

A 
Better prognosis (7.5yr median survival vs 4.5)
( most likely in Bronchiectasis e.g. CF )
49
Q

indications for heart-lung transplant?

A

severe pulmonary hypertension

50
Q

Complications of lung transplant

A

ACUTE PHASE
• acute rejection (most pt will experience at least once in first 6/12)
• opportunistic infections

CHRONIC PHASE
• Bronchiolitis obliterans - usually a terminal event - >50% will develop some degree of BO 5y post-trans
• Cancer - post transplant lymphoproliferative disorder most common in first year/ skin malig
• Steroid SE
• Tacrolimus → diabetes, tremor
• Renal and hearing impairment from anti-rejection agents

51
Q

contraindications to lung transplant

A
  • Malignancy in last 5yr (or 2yr if low risk of recurrence)
  • BMI >35
  • Current smokers or substance abuse
  • Mental Health conditions that would preclude taking meds or attending clinic
  • Untreatable heart liver kidney or brain dysfunction
  • Atherosclerotic disease w end organ ischaemia
52
Q

Criteria to consider lung tranplant in end stage lung disease

A

> 50% chance of death within 2yr
80% chance of surviving >90 days post transplant
80% 5yr post tranplant survival from gen med perspective

(sick enough to need one, fit enough to survive, with no major comorbs)

53
Q

When to consider lung transplant in CF

A
  • Poor ET
  • Frequent exacerbations
  • FEV1 < 30%
  • Signif pulmonary artery hypertension
54
Q

Which lung condition carries the best post-transplant survival

A

CF

55
Q

Causes of increased vocal fremitus

A
  • Pneumonia
  • hyperinflation like COPD asthma
  • Lung abscess
56
Q

Causes of decreased vocal fremitus:

A
  • Pleural effusion
  • Pneumothorax
  • Emphysema
57
Q

yellow nail syndrome triad

A
  • Yellow nail discoloration
  • Pulmonary - bronchiectasis, pleural effusion
  • Lower limb lymphedema

Chronic sinusitis is frequently associated with the triad.

58
Q

Causes of bronchiectasis

A

Bronchiectasis can be idiopathic (40%)

Other causes can include:
• Bronchiectasis can be idiopathic (40%)
• Recurrent infections Alcoholics/asp pneumonia
• childhood infections – , TB, measles
• Hypersensitivity - Allergic bronchopulmonary aspergillosis
• Inherited - CF, primary ciliary dyskinesia

59
Q

Tell me about Allergic bronchopulmonary aspergillosis (ABPA)

A

a hypersensitivity response to the fungus Aspergillus (most commonly Asp fumigatus)
causes bronchiectasis
Common in CF and asthma

60
Q

Dextracardia and chronic productive cough

A

Primary ciliary dyskinesia
• autosomal recessive genetic ciliary disorder
• Diagnose with ciliary function tests - can they taste saccharin 20m after placed in nose?!

OR if full situs invertus:
Kartagener’s syndrome
• autosomal recessive genetic ciliary disorder
• situs inversus, chronic sinusitis, and bronchiectasis

61
Q

Diagnosis of Allergic bronchopulmonary aspergillosis (ABPA)

A
  • Aspergillus skin test (AST)
  • Elevated IgE (Total, and specific serum to A. fumigatus)
  • Baseline CXR
  • HRCT
62
Q

respiratory causes of raised JVP

A

COPD or ILD
Chronic hypoxia leads to pulmonary vasoconstriction,then
pulmonary hypertension, causing R heart failure

63
Q

Hypertrophic pulmonary osteoarthropathy

A
  • periostitis
  • digital clubbing
  • painful arthropathy of the large joints (particularly lower limbs)
64
Q

How would you do a biopsy for ?Lung cancer

A 
Biopsies may be made via
• bronchoscopy
• endobronchial ultrasound
• percutaneously (under radiology)
• mediastinoscopy

LN also biopsied or FNA

Pleural effusions should undergo diagnostic pleural aspiration

65
Q

Causes of unilateral pleural effusion

A 
Likely exudative
• Lung malignancy
• Infection (parapneumonic, empyema)
• Infarction e.g. due to pulmonary embolus
• Inflammation: RA and SLE
66
Q

Causes of bilat pleural effusion

A

Likely Transudative
• Cardiac failure
• Liver failure - cirrhosis / hypoalbuminemia
• CKD

67
Q

How to distinguish between transudative and exudative pleural effusion?

A

Light’s criteria on a pleural aspirate.
Exudate if one or more of:
• pleural fluid : serum Protein ratio is > 0.5
• pleural fluid : serum LDH ratio is > 0.6
• pleural LDH >2/3 the upper limit of normal for the serum LDH

pH < 7.1 also suggests an exudate

68
Q

In pleural effusion, when would you drain?

A

• Symptomatic

Signs it is parapneumonic
• Pleural pH <7.2 is most important (or high LDH and low glucose, but less accurate)
• Purulent or turbid/cloudy
• Positive culture

69
Q

Most likely diagnosis in pneumonectomy

A

NSCLC for both pneumonectomy and lobectomy

70
Q

What drug treatments are used for interstitial lung disease?

A

For idiopathic pulmonary fibrosis:
• Pirfenidone
• Nintedanib

For patients with non-specific interstitial pneumonia/ground glass shadowing:
• Steroids
• Immunosuppressive therapy

71
Q

COPD classification of severity

A 
FEV1 compared to predicted 
•   >80% mild
•   50-80% moderate
•   30-50% severe
•   <30% very severe
72
Q

Pt with rheumatoid arthritis who presents with respiratory disease

A
  • ILD
  • bronchiectasis directly from RA, or from infections related to immunosuppression
  • obliterative bronchiolitis (this is obstructive, and rare)
73
Q

CXR sarcoidosis

A

Stage 0 - no abnormalities (5-10%)
Stage 1 - Bilateral hilar lymphad (50%)
Stage 2 - Bilateral hilar lymphad + pulmonary infiltrates (25-30%)
Stage 3 - Diffuse pulmonary infiltrates (10-12%)
Stage 4 - Pulmonary fibrosis 5%

74
Q

Treatment for sarcoidosis

A

Mostly supportive only
If severe symptoms or CXR of stage 2 or above, use systemic steroids
Methotrexate or anti TNF therapies can be used

75
Q

What is sarcoidosis

A

A granulomatous disorder that affects multiple organs

Cause is not known

76
Q

Diagnosis of sarcoidosis

A

transbronchial biopsy +ve in 90%

77
Q

pulmonary function tests in sarcoidosis

A

restrictive

decreased TLCO gas transfer

78
Q

Distinguish between bronchiectasis and ILD

A

Both have Fine creps , but they shift following a cough with bronchiectasis

ILD -restrictive
Bronch -obstructive

(both can have clubbing)

79
Q

PE Wells score

A 
4 points (PE likely) 
• DVT +3
• PE is top diagnosis  +3
• Tachy > 100  +1.5
• Immobilisation >3d OR surgery in 4w  +1.5
• Previous PE/DVT  +1.5
• Hemoptysis  +1
• Malignancy +1
80
Q

DVT Wells score

A

> = 2 likely

  • Malignancy
  • Immobilisation >3d OR surgery in 12w
  • Calf swelling (>3cm)
  • Superficial veins
  • Entire leg swollen
  • Localised tenderness along the deep venous system
  • Unilateral pitting oedema
  • Paralysis, paresis, or recent plaster immobilization of the lower extremity
  • Previous DVT
  • Alternative diagnosis (-2)
81
Q

Prolonged expiratory phase

A

Indicates obstructive picture
• COPD
• Asthma
• Bronchiectasis

(ILD is restrictive)

82
Q

Counselling for Patient with TB

A 
4 antibiotics 
6m of treatment
SE Liver 
Avoid alcohol
Check HIV etc

Isolation if multidrug-resistant TB until sputum becomes negative
Can force to keep under Public Health Act 1984

83
Q

Signs of Superior Vena Cava Obstruction

A
  • Dilated veins over the arms, neck and anterior chest wall
  • Oedema of the upper body, extremities and face
  • Severe respiratory distress

Exacerbated by Pemberton’s sign

84
Q

Causes of Superior Vena Cava Obstruction

A
  • Bronchiogenic carcinoma
  • NSCLC
  • SCLC

lymphoma and germ cell tumours responsible for a smaller but significant proportion

85
Q

Differential causes of obliterative bronchiolitis

A
  • Granulomatous polyarteritis (previously Wegner’s): saddle nose; obliterative bronchiolitis
  • Rheumatoid arthritis: wheeze secondary to obliterative bronchiolitis
  • Post‐lung transplant: obliterative bronchiolitis as part of chronic rejection spectrum
86
Q

indications for LTOT

A
  • Non‐smoker
  • PaO2 <7.3kPa on air
  • PaCO2 that does not rise excessively on O2

7.3-8 if:
• secondary polycythaemia
• pulmonary hypertension
• peripheral oedema

87
Q

causes of COPD

A
  • Smoking
  • industrial dust exposure
  • Alpha1 antitrypsin (basal disease)
88
Q

Obstructive spirometry

A

FEV1/FVC < 0.7

89
Q

mechanism behind CO2 retainers

A

In COPD, pt optimise their gas exchange by hypoxic vasoconstriction leading to altered alveolar VQ ratios

Excessive O2 causes increased blood flow to poorly ventilated alveoli, increasing VQ mismatch

90
Q

Management of Pulmonary hypertension

A
  • Treat any underlying causes
  • Prostacyclin analogues
  • Endothelin-A receptor antagonists
  • Phosphodiesterase-5 inhibitors
91
Q

Pulmonary hypertension causes

A
  • Idiopathic
  • Drug/toxin-induced
  • portal hypertension
  • HIV
  • Chronic hypoxia
  • Congenital HD
  • Systemic sclerosis, SLE , RA , Sjogren’s
92
Q

What is bronchiectasis

A

long-term condition where the airways of the lungs become widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection

93
Q

Cor pulmonale

A

RHF secondary to respiratory disease
(chronic hypoxia -> pul vasoconstriction -> pulmonary hypertension)

Main treatment is oxygen therapy / diuretics

94
Q

SOB without signs

A
  • Anaemia
  • Cancer
  • PE
  • Obesity hypoventilation
95
Q

Management for bronchiectasis

A
  • smoking cessation
  • vaccines
  • postural drainage
  • abx / prophylactic
  • Bronchodilators

Can consider lung resection
/transplant if FEV1 below 30% of predicted

96
Q

Treatment of cor pulmonale

A

LTOT

97
Q

Cor pulmonale signs

A
  • Raised JVP
  • Peripheral oedema
  • Loud S2
  • RV heave
  • S3 gallop
  • displaced/thrusting apex

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