Respiratory Flashcards
(130 cards)
1
Q
Complications of lung cancer?
A
SVCO: suffused + oedematous face and upper limbs, dilated superficial chest veins, stridor
RLN palsy: hoarse voice, bovine cough
Horner’s sign + wasted small muscles of the hand (Pancoast’s tumour)
Gynaecomastia (ectopic beta-HCG)
Neuro: LEMS, peripheral neuropathy, proximal myopathy, paraneoplastic cerebellar degeneration
Derm: dermatomyositis (heliotrope rash on eyelids and purple papules on knuckes - Gottron’s papules), acanthosis nigricans
2
Q
Different types of lung cancer and their paraneoplastic complications?
A
SCLC (24%):
- ADH-secreting tumour causing SIADH and hyponatraemia
- ACTH-secreting tumour causing Cushing’s syndrome
- LEMS
NSCLC:
- Squamous cell (35%): causes PTHrP release and hypercalcaemia
- Adenocarcinoma (21%)
- Large cell (19%)
- Alveolar (1%)
3
Q
What are the treatment options available for SCLC and NSCLC?
A
NSCLC:
Surgery - lobectomy / pneumonectomy
Radiotherapy
Chemotherapy (erlotinib)
SCLC:
6 courses of chemotherapy, SCLC is rarely resectable due to late presentation
4
Q
Investigations for suspected lung cancer to guide management?
‘ICSL’
A
- Imaging
- CXR: collapse, mass, hilar lymphadenopathy
- volume acquisition CT thorax with contrast (so small tumours not lost between slides) - Cell type
- induced sputum cytology
- biopsy by bronchoscopy or needle-guided CT - Staging
- CT / bronchoscopy / EBUS guided biopsy / thoracoscopy / PET-CT
- NSCLC: TNM to assess operability
- SCLC: limited or extensive disease - Lung function tests for operative assessment
- Pneumonectomy FEV1 >2L
- Lobectomy FEV1 >1.5L
5
Q
Ddx for a lateral thoracotomy scar with normal underlying lung?
A
Lobectomy (hyperinflation of other lobes masks signs)
Bullectomy
Lung transplant
Open lung biopsy
Pleurectomy
Decortication (ie for empyema / pleural tumours)
6
Q
Lateral thoracotomy scar with rib resection - likely underlying pathology?
A
Suggests thoracoplasty for TB in the past. Look for phrenic nerve crush scar, kyphosis and apical fibrosis, suggestive of TB.
7
Q
Please list the criteria for lung surgery (lobectomy / pneumonectomy)
A
Lobectomy FEV1 >1.5 L
Pneumonectomy FEV1 >2L
Transfer factor >50%
No evidence of severe pulmonary HTN
No metastases
Good WHO functional status
8
Q
Differential for a lung surgery patient with a median sternotomy scar?
A
May indicate a heart and lung transplant for pulmonary HTN, or congenital heart disease causing Eisenmenger’s syndrome.
9
Q
Differential diagnosis for a clamshell incision scar?
A
Clamshell scar suggests:
Bilateral lung transplant for
- Cystic fibrosis
- Bronchiectasis
- COPD
- A1AT deficiency
- Pulmonary fibrosis
- Pulmonary artery HTN
- Sarcoidosis
10
Q
Ddx for lateral thoracotomy scar with abnormal underlying lung?
A
Lobectomy
Pneumonectomy
Lung volume reduction surgery (COPD)
Bullectomy
Lung transplant with complications
11
Q
Different lung surgery cases and their indications
A
Open lung biopsy
Lung volume reduction surgery (COPD)
Single-lung transplant (pulmonary fibrosis, A1AT deficiency, sarcoidosis)
Pleurectomy (recurrent pneumothoraces / effusions)
Bullectomy (COPD)
Thoracoplasty (TB)
Decortication (empyema)
12
Q
Complications of lung transplantation?
A
Rejection (acute and chronic) including bronchiolitis obliterans syndrome
Infection: CMV, HSV, PCP, aspergillus, bacterial pneumonia
Immunosuppression side effects
13
Q
What findings on examination might indicate bronchiolitis obliterans syndrome post-lung transplant?
A
Fine late crepitations
14
Q
Contraindications to lung transplant?
A
Malignancy within the last 5 years
Patients with very high or low BMI
Still smoking / using illicit drugs
Mental health conditions that would preclude them from taking medications on a regular basis / unable to attend clinic appointments
15
Q
What medications are used following lung transplant?
A
Steroid, MMF and CNI (tacrolimus)
Ciclosporin historically used but increases risk of kidney disease
Prophylactic medication to prevent opportunistic infection
16
Q
Criteria for considering lung transplant?
A
> 50% risk of death from lung disease within 2y
> 80% likelihood of surviving at least 90 days post-transplant
> 80% likelihood of a 5-year post-transplant survival provided adequate graft function
17
Q
Most common indications for lung transplant?
A
Cystic fibrosis
Bronchiectasis
Pulmonary vascular disease
Pulmonary fibrosis
COPD (single lung transplant)
18
Q
Why perform a double lung transplant over a single?
A
Prognosis is better from a double transplant
Normally patients with bronchiectasis and CF receive a double transplant (‘wet’ lung conditions)
Patients with pulmonary vascular disease, fibrosis and COPD usually receive a single lung transplant
19
Q
Clinical findings expected in a patient who has previously had a lung transplant?
A
Clamshell thoracotomy incision on front of chest
Intercostal drain site scars
Previous scars from tracheostomy + central line
Is transplant working well? Yes, if no evidence of cyanosis and supplemental o2
Underlying aetiology of condition necessitating lung transplant (clubbing, think bronchiectasis or fibrosis)
20
Q
What type of lung cancer would require a lobectomy?
A
SCLC is often disseminated at the time of diagnosis, therefore is not amenable for treatment with surgery.
Patients with NSCLC, if caught early, can be surgically managed.
21
Q
You suspect a patient has lung cancer and staging has confirmed a potentially cancerous mass - how do you proceed?
A
Requires a tissue diagnosis, which can be obtained by: bronchoscopy, radiologically-guided biopsy, endobronchial ultrasound (EBUS).
Could also biopsy any LNs affected.
Could send aspiration of pleural effusions for cytology.
If cancer is caught at an early stage and a curative approach is desired, a PET-CT would be indicated.
22
Q
List some surgical COPD management options.
A
Bullectomy (if bulla >1L and compressing lung)
Endobronchial valve placement
Lung volume reduction surgery
Single lung transplant
23
Q
How is an acute exacerbation of COPD managed?
A
Controlled o2 to achieve sats of 88-92% via venturi mask
Salbutamol and ipratropium nebs
Antibiotics: penicillin / macrolides / tetracycline
Steroids 7 days
Aminophylline: not recommended as 1st line due to side effects
Discharge planning with community COPD treatment team
(Calculate DECAF score: predicts in-hospital mortality for acute exacerbation of COPD - Use in patients ≥35 years old, hospitalized with a primary diagnosis of acute exacerbation of COPD). Dyspnoea scale, eosinopenia, consolidation on CXR, acidaemia, AF
24
Q
Management of COPD?
A
Medical: depends on severity as per MRC dyspnoea scale (new 2023 guidance)
- Short-acting bronchodilators (SABA / SAMA)
- Long-acting bronchodilators (LABA / LAMA)
- If asthmatic features or steroid-responsive, LABA + ICS. If no asthmatic features or not steroid-responsive, LABA + LAMA.
- LABA + LAMA + ICS
- Theophylline: not recommended for initial treatment
NB: don’t give ICS if patient has had an episode of pneumonia (TORCH trial)
Additionally:
Smoking cessation / nicotine replacement therapy
Pulmonary rehab
Exercise, pneumonoccal / influenza vaccination
LTOT if meets criteria
25
What are the inclusion criteria for LTOT?
Pa02 <7.3 kPa on air or
Pa02 <8 kPa + cor pulmonale
Non-smoker
Must have 2-4 L/min via nasal cannula for at least 15h per day. Shown to increase average survival by 9 months.
26
Clinical signs expected in a patient with COPD?
Inspection: nebs / inhalers / sputum pot / dyspnoeic / central cyanosis / pursed lips (own PEEP)
CO2 retention flap, bounding pulse, tar-stained fingers
Hyper-expanded barrel-shaped chest
Resonant percussion note with loss of cardiac dullness
Expiratory polyphonic wheeze and reduced breath sounds at apices
Cor pulmonale: raised JVP, pedal oedema, RV heave, loud P2 and pansystolic murmur (tricuspid regurgitation)
COPD does not cause clubbing - if present, consider lung cancer or bronchiectasis
27
Investigations in a patient with suspected COPD?
Bedside: observations, full history, sputum culture, BMI and echo
Bloods: WCC (infection), A1AT levels, low albumin (for severity), ABG (T2RF)
Imaging: CXR (hyper-expanded or pneumothorax)
Special: spirometry (low FEV1, FEV1/FVC reduced ratio below 0.7 - obstructive defect). Low gas transfer.
28
Organisms causing acute exacerbation of COPD?
60% infection: viruses (influenza, adenovirus, rhinovirus), bacteria (haemophilus influenzae, strep pneumoniae, moraxella catarrhalis)
30% unknown aetiology
10% environmental pollution
29
Treatment options for empyema?
Pleural drainage + IV abx
Intrapleural DNAse + TPA (MIST2 trial)
Surgical decortication
30
Causes of pleural effusions?
Exudate (high protein) - often unilateral
- parapneumonic effusion
- lung infarction
- lung malignancy
- CTD such as RA
Transudate (low protein) - often bilateral
- cardiac failure
- liver failure
- chronic kidney disease
- hypoalbuminaemia
31
What do you send the pleural aspirate for in a pleural effusion?
LDH + protein: Light's criteria to determine if transudate or exudate
pH, culture, cell count, cytology
glucose and triglycerides: if RA / chylous effusion suspected
32
How do you differentiate between a transudative and exudative pleural effusion?
If protein is <25 g/L, transudate. If >35 g/L, exudate. If between 25-35 g/L:
Apply Light's criteria:
1. Pleural protein divided by serum protein >0.5
2. Pleural LDH divided by serum LDH >0.6
3. Pleural LDH is greater than 2/3 the upper limit of normal for serum LDH
33
If the cause of an exudative pleural effusion is not clear after application of Light's criteria, which further investigations can be performed?
Contrast-enhanced CT scan
Pleural biopsy
Medical thoracoscopy to take biopsies and perform talc pleurodesis
34
When would you drain a pleural effusion?
Would be guided by the pleural aspirate. If:
- pH <7.2
- there was frank pus coming out
- culture positive
Then drainage is indicated.
If none of the above are present, would only drain effusion if large or patient is very symptomatic.
35
List some causes of pleural effusions that are low in glucose?
'MEAT'
Malignancy
Empyema
Arthritis (RA)
TB
36
Clinical signs expected on examination of a patient with a pleural effusion?
Asymmetrical, reduced chest expansion
Trachea / mediastinum pushed away from the side of the effusion
Stony dull percussion note
Absent tactile vocal fremitus
Reduced breath sounds
Bronchial breathing above the effusion
37
How would you manage a pleural effusion that is secondary to malignancy?
As long as the underlying cancer has been diagnosed, the effusion could be drained.
Subsequent management includes:
- can insert long-term catheter to drain further pleural effusions
- pleurodesis (medically or via thoracoscopy)
38
List some complications of pneumonia.
Lung abscess
Parapneumonic effusion or empyema
Haemoptysis
Septic shock / multi-organ failure
39
Common causative organisms of a CAP?
Strep pneumoniae 50%
Mycoplasma pneumoniae 6%
Haemophilus influenzae (if COPD)
Chlamydia pneumoniae
1st line tx: penicillin or cephalosporin + a macrolide
40
How would you score a CAP and what is the value of doing so?
CURB-65 score.
Confusion
Urea >7
RR >30
BP <90 systolic of <60 diastolic
Age >65
Value is that it is used to guide management and prognostication - it is used to predict in-hospital mortality for CAP. Severe CAP should receive high-dose IV abx and level 2 care on HDU/ITU.
41
Investigations that you would request in a case of suspected CAP?
Bedside: obs, o2 sats, sputum sample, urine for legionella and pneumococcal antigens, and haemoglobinuria (mycoplasma causes cold agglutinins)
Bloods: blood cultures, WCC, U+E, CRP, atypical serology (admission and on day 10), immunoglobulins
Imaging: CXR (consolidation, air bronchogram, abscess, effusion)
42
Management of interstitial lung disease?
MDT approach: PT / OT / respiratory nurses
Treat underlying connective tissue disorder if present
Steroids: if ground glass shadowing on HRCT (NSIP)
Pirfenidone if UIP / IPF (anti-fibrotic agent)
N-acetylcysteine (free radical scavenger)
Single lung transplant
43
What is the prognosis of interstitial lung disease?
Very variable, depends on aetiology of ILD.
Ground glass infiltrate (NSIP) responds to immunosuppression (80% 5y survival)
Honeycombing on CT (UIP) has no response to steroids - 80% 5y mortality
44
Clinical features expected in a patient with interstitial lung disease?
Clubbing, central cyanosis, tachypnoea
Fine end-inspiratory crackles (like velcro, don't change with coughing)
Signs of associated autoimmune diseases (eg RA, SLE and systemic sclerosis)
Grey, discoloured skin (amiodarone)
NB describe findings as 'interstitial lung disease' when there isn't a clear cause.
45
What are the typical pulmonary function test results for a patient with pulmonary fibrosis?
Spirometry shows a restrictive pattern
A reduction in both FEV1 and FVC with a preserved ratio of >0.8
Reduced total lung capacity
Reduced transfer factor
46
Causes of upper zone lung fibrosis?
BREAST
Berylliosis
Radiation
Extrinsic allergic alveolitis
Ankylosing spondylitis
Sarcoid
TB
47
Causes of lower zone lung fibrosis?
RATIO
**R**heumatoid arthritis
**A**sbestosis
Connective **T**issue Disease
**I**PF / Hamman-Rich syndrome
**O**ther: bronchiectasis, chemical, drugs (MTX, nitrofurantoin)
48
What type of interstitial lung disease is associated with autoimmune diseases?
NSIP. Ground-glass changes on HRCT. Often apical, steroid-responsive.
49
What investigations would you request in a patient with suspected interstitial lung disease?
Bedside: observations, Sa02
Bloods: FBC (anaemia, infection), UE, CRP/ESR, ABG, CTD screen (RF, dsDNA, ANA, ANCA), LFTs (baseline if starting meds)
Imaging: CXR (for baseline), HRCT (looking for honeycombing (UIP) or ground-glass changes (NSIP)
Special: echo (right heart function, pulmonary HTN), spirometry (preserved FEV1/FVC ratio, reduced TLCO and KCO). BAL (to exclude infection prior to immunosuppression), lung biopsy.
50
Pulmonary complications of rheumatoid arthritis?
ILD
Pleural effusions
Pleuritis
Raised hemidiaphragm
Obliterative bronchiolitis (obstructive disease)
Pulmonary nodules (seropositive patients)
51
What are the features of the 'rheumatoid lung'?
LIPO
Lung fibrosis
Intrapulmonary nodules
Pleural effusions
Obliterative bronchiolitis
52
Stepwise management of asthma?
Stepwise approach as per BTS.
1. Short-acting beta agonist (SABA)
2. SABA + ICS
3. SABA + ICS + LABA
4. Add in montelukast
If none successful, may require use of oral steroids / referral to asthma specialist.
NB only **BETA** agonists in asthma - can use muscarinic in COPD
53
List some causes of airflow obstruction.
Asthma
Bronchiectasis
Obliterative bronchiolitis (a graft-host response following lung transplantation)
54
What two lung conditions does a polyphonic wheeze generally indicate?
Asthma or COPD
NB the age of the patient may guide you to the diagnosis.
55
How might spirometry differ between a patient with asthma and COPD?
In both asthma and COPD, would expect an obstructive picture on spirometry.
Reduced FEV1 and preserved FVC, with a reduced FEV1:FVC ratio.
BUT would expect an improvement following bronchodilator with asthma (15% improvement), but not COPD.
56
How could you use peak flow in the diagnosis of asthma?
A peak flow diary: to see if there is evidence of diurnal variation - showing that the asthma is not well-controlled.
Looking to see if there is a reduction in peak flow in the morning.
57
What would you look for on the FBC in a patient with suspected asthma?
WCC may be raised due to concomitant infection, or if the patient has recently been on a course of steroids.
Eosinophil count may also be raised due to asthma.
58
List the clinical signs of pulmonary hypertension.
Loud P2
RV third heart sound
Parasternal heave (represents RVH)
Elevated JVP + ascites (right HF)
Signs of tricuspid regurgitation
59
List the types of pulmonary artery hypertension.
Idiopathic PAH
Interstitial lung disease related
Cardiac: due to LVSD
Thromboembolic (chronic PEs)
Miscellaneous: lymphangioleiomytomatosis
60
Indications for heart-lung transplant?
Pulmonary artery disease (PAH)
Eisenmenger's syndrome from VSD / congenital heart defect
61
Causes of bronchiectasis?
Postinfective bronchial damage: bacterial / viral pneumonias, measles, pertussis, TB, mycobacterial infections
Mucociliary clearance defects: CF, primary ciliary dyskinesia, Kartagener's syndrome, Young's syndrome
Immune underactivity: primary immunoglobulin deficiency (hypogammaglobulinaemia and CVID), secondary immunodeficiency (HIV)
Mechanical: obstruction (tumour, foreign body)
Immune overactivity: ABPA, IBD-associated
62
List some complications of bronchiectasis.
Cor pulmonale
Secondary amyloidosis
Massive haemoptysis (mycotic aneurysm)
63
Define bronchiectasis.
Abnormal and permanently dilated airways with bronchial wall thickening.
This manifests as a cough with production of thick sputum.
64
Management of bronchiectasis?
Physio: active cycle breathing
Prompt antibiotic therapy for exacerbations
Long-term prophylactic abx with low-dose azithromycin 3x a week
Bronchodilators / inhaled corticosteroids if any airflow obstruction
Surgery: occasionally used for localised disease
65
Investigations for a patient with suspected bronchiectasis?
Bedside: obs, history, sputum culture with cytology
Bloods: immunoglobulins (hypogammaglobulinaemia), rheumatoid serology, saccharine ciliary motility test (Kartagener's)
Imaging: HRCT (looking for 'signet ring' sign - bronchi larger than adjacent vascular bundle), CXR (tram lines, ring shadows)
Special: genetic testing (CF), Aspergillus RAST skin prick testing (ABPA)
66
What is the pathophysiology of CF?
Autosomal recessive condition caused by mutations in the CFTR gene, most common mutation is delta F508.
Leads to chloride channel abnormalities, which results in increased salt excretion which can manifest as thick mucus which affects the respiratory system, GI tract and reproductive system.
67
Please list some manifestations of cystic fibrosis.
CF is a multi-system disease.
Predominantly affects respiratory system - causing patients to acquire bronchiectasis.
Affects digestive system leading to pancreatic exocrine insufficiency where patients require treatment with Creon and fat soluble vitamins (ADEK), and endocrine insufficiency: diabetes.
Liver: cholestasis, gallstones, cirrhosis and liver failure.
Kidney stones.
Reproductive system: absent vas deferens in males, rendering them infertile.
68
What are some of the management options for patients with cystic fibrosis?
Needs to be managed by the MDT in a specialist centre.
Regular chest physio and enhanced breathing exercises to help clear mucus.
Regular nebuliser therapy: mucolytics (DNAse), nebulised antibiotics (colistin and tobramycin).
Creon tablets and vitamin therapy.
Nutritional supplementation: gastrostomy tubes - can get 'button' gastrostomy which is more discreet.
CFTR modulators: Ivacaftor for patients that carry mutations that respond to these therapies. Now use triple therapy.
69
Discuss some of the commonly colonised bacteria in CF patients.
Different patients have different profiles of bacteria that are colonised in their chest.
Most common is Pseudomonas aeruginosa.
Infection with Burkholderia cepacia complex or Mycobacterium abscessus may render a patient ineligible for lung transplant in some centres.
70
How is CF commonly diagnosed in the UK?
All infants in the UK are screened via the Guthrie test at a few days old.
If suspected, the diagnosis of CF can be made by screening for the most common CFTR mutations via a blood sample, and the sweat test. In CF, a chloride content of >60 mmol/l will be found.
71
What is the life expectancy for a patient with CF?
Current life expectancy in the UK is 47 years, and children born with CF today can expect to live into their 50s.
NB it is variable depending on the mutation they carry and their adherence to treatment.
71
List some historical surgical techniques used to treat TB.
Plombage: insertion of polystyrene balls into the chest cavity.
Phrenic nerve crush: diaphragm paralysis
Thoracoplasty: rib removal, lung not resected
Apical lobectomy
Recurrent induced pneumothoraces
72
List some drugs used to treat TB, and their side effects.
Rifampicin - hepatitis, increased drug metabolism
Isoniazid - peripheral neuropathy (prescribe pyridoxine), hepatitis
Pyrazinamide - hepatitis
Ethambutol - retro-bulbar neuritis and hepatitis
NB prior to commencing anti-tuberculous therapy, must check visual acuity and baseline LFTs
73
What are common indications for a VATS procedure?
Wedge resection
Decortication (RA, chronic infection, mesothelioma)
Bullectomy
Lobectomy
Recurrent PTX
74
What are the benefits of VATS?
Smaller incision
Reduced pain
Reduced wound complications
Redued length of stay
75
What are the possible indications for a lobectomy?
Lung cancer
Aspergilloma
TB
Lung abscess
76
Investigations for lung cancer?
Staging CT TAP
Tissue diagnosis
Functional imaging (PET CT)
Working up patient for surgery
77
How would you assess fitness for surgery?
Full lung function tests including transfer factor assessment
Cardiopulmonary excercise testing
78
What is the VO2 max threshold that offers a good post-op outcome?
VO2 Max 15ml/kg/min
79
What are the clinical signs differences between a pneumonectomy and lobectomy?
Lobectomy
Trachea may not be deviated
Normal/reduced breath sounds
Percussion note normal
Pneumonectomy
Trachea always deviated
towards
Absent breath sounds
Dull percussion note
80
What are the indications for surgical management of pneumothorax?
Persistent air leak
Inadequate lung expansion
Recurrent pneumothorax
81
What is the management of a pneumothorax?
Primary
<2cm and asymptomatic - discharge and repeat CXR
>2cm or symtomatic - aspiration. If aspiration fails, chest drain
Secondary
Chest drain if: >50y, >2cm, SOB
If 1-2cm aspirate followed by chest drain if not resolved.
If <1cm = oxygen and admit for 24 hours
82
What improvement would you expect when performing peak flow following bronchodilator therapy in asthma?
Improvement in 200ml on peak flow, or an improvement by 15%
83
Differential for bibasal crepitations?
Bronchiectasis (coarse and clear with coughing)
Bilateral pneumonias
Congestive heart failure (elevated JVP)
Fibrosis (fine)
84
How do you investigate fibrosis?
Bloods: ESR, RF, ANA
CXR
ABG
Lung function tests (restrictive picture)
Bronchoalveolar lavage (excludes infection, and neutrophil-to-lymphocyte ratio
HRCT
85
What are the spirometry findings of fibrosis?
Reduced FEV1
Reduced FVC
Preserved/high FEV1/FVC ratio
Reduced TLC
Reduced transfer factor
86
Treatment of ILD?
MDT
Treat underlying connective tissue disorder
If groundglass / NSIP = steroids
IPF: anti-fibrotic agent pirfenidone/ninetanib
Transplant
87
CTDs that cause ILD?
RA, SS, SLE, Dermatomyositis
88
Broadly speaking, how can we categorise interstitial lung disease?
| 'CIDO'
CTD-related
Idiopathic
Drug exposure
Occupational
89
Respiratory complications of CF?
ABPA
PTX
Haemoptysis (may be massive or chronic)
Hypoxia
Sinus disease and nasal polyps
Chronic infection - pseudomonas or Burkholderia cepacia or mycobacaterium abscessus
90
What common conditions are lung transplants performed for?
ILD (usually single)
CF (usually double)
COPD (40% of transplants)
Pulmonary vascular diseases
91
What are the complications of lung transplant?
Hyper-acute rejection
Hyper-acute graft dysfunction (ischaemic reperfusion)
Chronic rejection (bronchiolitis obliterans syndrome)
Infections
Malignancy
92
What is the COPD BODE index?
FEV1 (% of predicted)
6 minute walk distance
MRC Dyspnoea scale
Estimates 4 year survival
93
What are the contraindications to lung transplant?
BMI >35
Untreated other organ system
Unstable critical condition
Chest wall deformity
Substance misuse
Poor adherence
94
Post- lung transplant mortality?
20% at 1 year
50% at 5 years
95
What is yellow nail syndrome?
Bronchiectasis
Pleural effusions
Lymphoedema
changes with coughing
Dystrophic, discoloured, thickened nails
96
How would you investigate someone with bronchiectasis?
Routine bloods
HIV, Ig, Aspergillus serology, CF, Rheumatoid serology
Sputum analysis (gen, fungus, mycobacterium)
CXR
Spirometry
HRCT
Saccharine ciliary motility test: Kartagener’s
97
What are the radiological findings of bronchiectasis?
CXR: tramlines and ring shadows
CT: Signet ring sign (thickened dilated bronchi that are larger than the adjacent vascular bundle)
98
Management of bronchiectasis?
MDT
Chest physio: postural drainage
Hypertonic saline nebs and bronchodilators
Long-term antibiotics (azithromycin)
Sputum culture guided IV abx (14 days - extended course)
Neublised antibiotics in pseudomonas
Vaccination - pneumococcal and annual influenza
99
Causes of bronchiectasis?
Congenital: CF, Kartagener’s
Post-infectious bronchial damage: Measles, TB
Immune over-activity: ABPA, IBD
Immune under-activity: Hypogammaglobulinaemia, CVID
Aspiration: GORD, alcohol
100
What targeted treamtent in NSCLC do you know of?
EGFR (osimertinib)
ALK (repotrectinib)
PD-L1 (nivolumab)
101
What paraneoplastic syndromes do you know if in small cell lung cancer?
LEMS
ACTH - Cushing's syndrome
SIADH
102
What will you send your pleural sample off for if you have a unilateral pleural effusion?
pH
Protein
LDH
Cell count and cytology
Gram stain + AFB staining
Culture
103
How to differentiate between a transudate and exudate in a pleural effusion?
<25g/L: transudate
>36g/L: exudate
25-35g/L: apply Light’s criteria
Exudate if:
Pleural : Blood protein ratio >0.5
Pleural : Blood LDH ratio >0.6
Pleural LDH >2/3 the upper limit of normal blood levels
Transudate:
Heart Failure
Liver failure
Nephrotic syndrome
Hypothyroidism
Meig’s syndrome
Exudate:
Infection
Malignancy
CTD
Pancreatitis
Yellow nail syndrome
PE
Dressler’s
104
What other assays are useful when investigating a pleural effusion?
Low glucose in sample = infection, malignancy, oeseopheal rupture
Very low glucose = RA
High amylase in pancreatitis
Cell count = higher WCC with neutrophilia in paraneumonic; lymphocytosis in TB
105
What is cor pulmonale?
RHF due to respiratory disease. Causes pulmonary vasoconstriction.
106
What bronchiectasis syndromes do you know?
ABPA
Yellow Nail syndrome
Primary ciliary dyskinesia
Young syndrome
Kartagener’s syndrome
Chediak-Higashi (AR, chronic granulomatous disease of the lung)
107
What types of smoking cessation do you know?
NRT - short courses
Varinecline - partial nicotinic receptor agonist. CI self-harm/suicide/pregnancy/breastfeeding.
Buprenorphine - nicotinic receptor antagonist, norepinephrine and dopamine re-uptake inhibitor. CI pregnancy/breastfeeding.
108
What clinical feature would most likely suggest chronic lung transplant rejection?
Bronchiolitis obliterans producing an obstructive lung defect.
109
What are the features of EGPA?
Asthma
Eosinophilia
Paranasal sinusitis
Mononeuritis multiplex
pANCA + in 60%
110
What are the features of GPA?
Not eosinophilic
Epistaxis, crusting, sinusitis
Haemoptysis
RPGN
Saddle shaped nose deformity
Vasculitic rash, CN lesions
cANCA in 90%
111
What is the treatment of GPA?
Steroids
Cyclophosphamide (90% response rate)
Plasma exchange
112
What are the principles of treatment of CF?
MDT
Physiotherapy - postural drainage is critical
Pancrease, fat soluble supplements
Mucolytics (DNAse)
Double lung transplant
Gene therapy
CFTR potentiators (caftors - lumacaftor, ivacaftor)
113
What would you be thinking of if a patient with IPF and a single lung transplant started developing progressive SOB and an obstructive defect on spirometry?
I would be concerned about bronchiolitis obliterans.
Would want to involve the transplant team early, who may wish to perform a bronchoscopy with a transbronchial biopsy.
114
What malignancies would you be concerned about in a patient with post-transplant weight loss?
Immunosuppression-related malignancies such as skin malignancy and post-transplant lymphoma.
115
Features on examination of pulmonary HTN?
Loud P2 and right ventricular heave.
116
What is obliterative bronchiolitis and what is its relevance post-transplant?
Can occur in chronic lung transplant rejection.
Progressive airflow obstruction, obstructive defect on lung function testing.
117
What are the possible indications for video-assisted thorascopic surgery (VATS)?
Lobectomy
Wedge resection
Decortication for empyema
Bullectomy
Pleurectomy for recurrent pneumothoraces
118
What is the difference between a primary and a secondary pneumothorax?
A primary spontaneous pneumothorax is a pneumothorax in an otherwise healthy person.
A secondary pneumothorax is one that occurs in the context of underlying lung disease.
119
Is there any role for suction in the management of pneumothorax?
Chest drain suction is very rarely used (as it carries a risk of re-expansion pulmonary oedema).
If used, high-volume, low-pressure systems are recommended.
120
Management of bronchiectasis?
MDT-guided management
Chest physiotherapy
Mucolytics: nebulised hypertonic saline
Long-term azithromycin as prophylaxis
Acute courses of abx guided by sputum cultures for management of acute infections
For patients who have pseudomonas infection, nebulised antibiotics may be required.
121
Investigations to perform in suspected bronchiectasis?
Bedside: sputum culture sent for general, fungal and mycobacterial culture.
Bloods: HIV, immunoglobulin, pneumococcal, aspergillus (ABPA), autoimmune screen (CTD) and genetic testing for CF.
Imaging: CXR, HR-CT.
Other: spirometry, nasal biopsy if primary ciliary dyskinesia suspected.
122
What are the different histological types of lung cancer?
Lung cancer can be divided into small cell and non-small cell.
NSCLC can be further subdivided into:
- adenocarcinoma
- squamous cell carcinoma
- large cell
- neuroendocrine tumours
(Don't forget - metastasis to lung also)
123
What are the different causes of ILD?
**Idiopathic pulmonary fibrosis:** sarcoid, cryptogenic organising pneumonia, IPF, respiratory bronchiolitis-ILD, acute interstitial pneumonia (AIP) and NSIP.
**Occupational disorders**: silicosis and asbestosis
**CTDs** such as RA or SLE
**Drug-induced**: MTX, nitrofurantoin and amiodarone
(Remember that ILD can be divided into UIP (honeycombing on CT) and NSIP (steroid-responsive, GG changes on CT))
124
What might indicate that the aetiology of ILD is idiopathic pulmonary fibrosis on examination?
If the patient is >50y
If the patient is clubbed
125
Appropriate investigations in suspected ILD?
Bedside: PFTs - spirometry and transfer factor
Bloods for connective tissue disorders and allergy testing (eg avian preciptins), ABG
Imaging: CXR, HR-CT
126
What is the prognosis of idiopathic pulmonary fibrosis?
IPF carries the poorest prognosis of all the interstitial lung diseases.
Median survival 2-3y from diagnosis.
20-30% of patients survive 5y from diagnosis.
Poor prognostic factors: old age, dyspnoea, low/declining resp function, pulmonary artery hypertension, co-existing emphysema, exertional desaturation or UIP on histology.
127
When are the antifibrotics used to treat UIP / IPF?
Nintedanib or Perfenidone are considered in patients with FVC of between 50-80% predicted to slow disease progression.
Pts with no absolute contraindications should be referred for consideration of lung transplantation.
128
What is cor pulmonale and how is it treated?
Cor pulmonale is right sided heart failure secondary to pulmonary disease.
It occurs in patients who are chronically hypoxic. The chronic hypoxia leads to pulmonary vasoconstriction which leads to pulmonary HTN, which leads to right sided heart failure.
The mainstay of treatment for cor pulmonale is long-term oxygen therapy. We also give diuretics to relieve congestion from the right-sided heart failure.
129
What is the danger of giving steroids to patients with COPD?
The increased incidence of pneumonia.
We only give these to patients with high-level exacerbations of COPD.
