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Respiratory Flashcards

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1
Q

What are the indications of thoracotomy scar (anterior or posterior)

A
  • lobectomy
  • pneumonectomy
  • open lung biopsy
  • lung volume reduction/bullectomy
  • single lung transplants
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2
Q

What are the indications of clamshell incision scar

A
  • bilateral lung transplant
  • widespread traumatic chest injury requiring bilateral access
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3
Q

What are the indications of VATS

A
  • biopsy/removal of masses/LNs
  • pleurodesis for recurrent effusion
  • recurrent PTX
  • lobectomy/segmentectomy
  • bullectomy
  • decortication
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4
Q

What are the benefits of VATS over open thoracotomy

A
  • reduced pain
  • reduced wound complications
  • reduced healing time
  • reduced length of stay
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5
Q

What are the main indications of a lobectomy

A
  • lung cancer
  • infection (aspergilloma/TB), lung abscess
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6
Q

What FEV1 is preferred for lobectomy

A

> 1.5

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7
Q

What FEV1 is required for a pneumonectomy

A

> 2

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8
Q

What VO2 max confers good prognosis after thoracotomy

A

VO2 max > 15ml/kg/min

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9
Q

Can examination of chest after lobectomy be normal?

A

Yes if operation was some time ago, adjacent lope can hyperinflate

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10
Q

Which NSCLC is most strongly associated with smoking

A

SCC

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11
Q

What is the benefit of thoracotomy over VATS for pneumothorax

A

Thoracotomy has reduced risk of recurrence of PTX

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12
Q

What are the causes of bilateral pleural effusion

A

CCF, hypoalbuminaemia, renal failure, liver failure, SLE/other AI causes, widespread malignancy, bilateral PE

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13
Q

What are the causes of obstructive airway disease

A

Asthma, COPD, bronchiectasis, Bronchiolitis obliterans

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14
Q

Which lung condition causes fixed airway obstruction after lung transplant

A

Bronchiolitis obliterans

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15
Q

What classes as reversibility on spirometry

A

200ml improvement in FEV1 or 15% change compared to baseline

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16
Q

What are the differentials for bibasal inspiratory crepitations

A

Pulmonary fibrosis
Bronchiectasis
Infection
Heart failure

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17
Q

What are the causes of a low TLCO (transfer factor)

A

Pulmonary fibrosis
Pneumonia
PE
Pulmonary oedema
COPD
Anaemia
Low cardiac output
Sarcoidosis

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18
Q

What are the causes of a raised TLCO (transfer factor)

A

Pulmonary haemorrhage
Asthma
Polycythaemia
Left-to-right cardiac shunt
Exercise

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19
Q

What causes increased KCO (transfer coefficient) with normal/low TLCO (transfer factor)

A

Pneumonectomy/lobectomy
Scoliosis

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20
Q

Which antifibrotic agents are used to treat IPF

A

Pirfenidone, nintedanib

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21
Q

What will pulmonary fibrosis show on lung function tests

A
  • Restrictive pattern (reduced FEV1 and FVC but normal ratios)
  • reduced total lung capacity
  • reduced transfer factor
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22
Q

What finding on HRCT suggests pulmonary fibrosis that will respond well to steroids

A

Ground glass changes (inflammation)

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23
Q

What are the 2 most common morphologies of ILD

A
  1. Usual interstitial pneumonia
  2. Non-specific interstitial pneumonia
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24
Q

What are the differences between UIP and NSIP

A

UIP: honeycombing, less responsive to steroids
NSIP: ground glass opacification, more responsive to steroids

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25
What is pneumoconiosis
Any lung disease causes by inhalation of dust and fibres - includes asbestosis, silicosis and coal workers pneumoconiosis
26
What is seen on HRCT in bronchiectasis
Signet ring sign
27
What is the surgical management of pulmonary fibrosis
Single lung transplant can be considered
28
What FEV1 is antifibrotic treatment indicated for IPF
50 - 80%
29
Is biopsy needed to diagnose IPF?
Not if the MDT is happy with the diagnosis from history, exam, PFTs and HRCT
30
When is biopsy useful in ILD
When there is diagnostic uncertainty after initial tests
31
How is ILD monitored after diagnosis
PFTs at 6 months to determine speed of progression and need for treatment
32
Which organism confers worse prognosis in cystic fibrosis
Burkholderia
33
Which organism is a direct contraindication for lung transplant in cystic fibrosis
Burkholderia
34
Where in the lungs does bronchiectasis tend to occur most in CF patients
Upper lobes
35
What is the non-pharmacological management of CF
1. MDT (CF specialist, PT, dietician, SN) 2. Daily chest physio (postural drainage) 3. Vaccinations
36
What are the indications of single lung transplant
COPD, pulmonary fibrosis
37
What are the indications of double lung transplant
CF, bronchiectasis, pulmonary hypertension
38
What is the leading cause of death after the first year of lung transplant
Bronchiolitis obliterans
39
What is the most common malignancy in the first year after lung transplant
Lymphoproliferative disorder
40
Which patients with UIP and fibrotic NSIP should be referred for consideration of lung transplant
All patients with UIP/fibrotic NSIP that have no absolute contraindications
41
When should CF patients be referred for lung transplant
FEV1 <30% Significant pulm HTN High exacerbation frequency Recurrent PTX Requirement for NIV
42
What is the most common indication for lung transplant worldwide
COPD (40%)
43
Which blood tests are important in bronchiectasis along with basics
HIV Immuloglobulins Aspergillus serology CF genetic testing if <40 yrs old
44
Which conditions might benefit from a positive expiratory pressure device
COPD, CF, bronchiectasis (helps bring up mucous)
45
What causes traction bronchiectasis
Bronchiectatic dilation from adjacent lung fibrosis
46
What are the causes of bronchiectasis
- CF, PCD - Immunodeficiency - Post-infectious - Rheumatological - ABPA - Yellow nail syndrome - Traction (PF) - Idiopathic
47
What is the most common lung condition associated with inflammatory myositis (eg polymyositis)
ILD
48
What are the differential diagnoses of reduced breath sounds with tracheal deviation
- Pneumonectomy - Collapse of a lobe - Pleural effusion (trachea deviated away) - Tension pneumothorax
49
What are the causes of lung collapse
- Intra-luminal: mucous plugging, FB - Luminal: dynamic obstruction (COPD), bronchial wall carcinoma - Extra-luminal: lymphadenopathy, mediastinal mass, primary/metastatic lung cancer - Atelectasis: compressive (effusion), adhesive (ARDS)
50
Why is spirometry important in the work up for suspected lung cancer
Will guide on suitability for surgery
51
Where are lung squamous cell carcinomas usually found
More centrally (adeno = peripheral)
52
What may be heard on auscultation of a patient with COPD
Expiratory polyphonic wheeze (crackles if consolidation too), reduced breath sounds at apices
53
What signs are suggestive of cor pulmonale
Raised JVP, ankle oedema, RV heave, loud P2 with PSM of TR
54
What distinguishes COPD from chronic asthma on investigations
Less reversibility - <15% change in FEV1 post-bronchodilator
55
Why are LFTs important in COPD
Low albumin indicates severity
56
What is the non pharmacological management of COPD
- *smoking cessation* - cessation clinics and NRT - pulmonary rehab - exercise - nutrition - vaccinations - pneumococcal and influenza
57
What is the surgical management of COPD
careful patient selection is important: - bullectomy (if bullae >1L and compressing surrounding lung) - lung reduction surgery (only suitable for a few pts with heterogenous emphysema) - single lung transplant
58
What are the indications for LTOT in COPD
- non-smoker - PaO2 <7.3 on RA - PaO2 <8 if cor pulmonale - PaCO2 does not rise on O2 Improves survival by 9 months
59
What are the differentials of a wheezy chest
*Bronchiolitis obliterans* - GPA (saddle nose) - Rheumatoid arthritis
60
What are the causes of a dull lung base on percussion
- pleural effusion (dull) - consolidation (crackles) - collapse (trachea towards) - previous lobectomy (scar) - pleural thickening (normal resonance) - raised hemidiaphragm
61
What organism causes rusty sputum
Pneumococcus
62
What will auscultation of pneumonia reveal
Focal course crackles, increases vocal resonance, bronchial breathing
63
What is the atypical screen for pneumonia
Serology: mycoplasma, chlamydia Urine antigen: legionella, pneumococcal
64
What are the most common organisms seen in pneumonia
1. Streptococcus pneumoniae 2. Mycoplasma pneumoniae 3. Haemophilus influenzae (COPD) 4. Chlamydia pneumoniae
65
Which organisms should be considered in pneumonia in the immunocompromised patient
- fungal - multi-resistant mycobacteria - PCP - CMV
66
How can severity of pneumonia be established
CURB-65 score: - Confusion - Urea >7 - RR >30 - BP <90 or <60 - Age >65
67
What are the complications of pneumonia
- sepsis - lung abscess - para-pneumonic effusion/empyema - haemoptysis
68
What were the historical surgical treatments for tuberculosis
1. Plombage 2. Phrenic nerve crush 3. Thoracoplasty 4. Apical lobectomy 5. Recurrent medical pneumothoraces
69
What are the serious side effects of rifampicin
Hepatitis Enzyme inducer (COCP)
70
What are the serious side effects of isoniazid
Hepatitis Peripheral neuropathy
71
What are the serious side effects of pyramzinamide
Hepatitis
72
What are the serious side effects of ethambutol
Hepatitis Retro-bulbar neuritis
73
What should be checked before starting TB treatment
Baseline LFTs Visual acuity
74
What should you advise patients about to start TB treatment in relation to side effects
1. Check eyes for jaundice 2. Monitor for change of colour vision 3. Secretions likely will turn orange 4. May develop paraesthesia 5. Use barrier contraception
75
What are the causes of an exudative pleural effusion
- malignancy (primary or secondary) - infection (parapneumonic) - infarction (PE) - inflammation (RA, SLE)
76
What are the causes of a transudate pleural effusion
- heart failure - liver failure - renal failure - hypoalbuminaemia
77
What are the two kinds of pleurodesis and what are their indications
1. Chemical 2. Mechanical Used for recurrent effusions, recurrent PTXs or persistent PTX
78
How can a tissue diagnosis of lung cancer be obtained
1. Bronchoscopy 2. CT guided biopsy 3. Lymph node biopsy 4. Pleural effusion cytology
79
What should pleural fluid be sent off for
- pH - protein (paired with serum) - LDH (paired with serum) - cytology - gram stain and culture - acid fast bacilli
80
What is suggestive of effusion secondary to RA on pleural aspirate
Very low glucose <1.6 mmol/L
81
Which way will the trachea be deviated in a pneumonectomy
Towards the side of the pneumonectomy
82
List the patterns of distribution of bronchiectasis according to underlying aetiology
CF -> upper lobes Others -> lower lobes ABPA -> proximal airways
83
What are the causes of normal spirometry but reduced gas transfer
- anaemia - pulmonary vascular disease
84
What are the causes of restrictive spirometry but normal gas transfer
Extrapulmonary restriction e.g. neuromuscular, scoliosis
85
What does a raised FeNO indicate on pulmonary function tests
Amount of inflammation in the lungs (used to aid diagnosis of asthma)
86
Which crackles are early inspiratory vs end inspiratory
Early inspiratory = bronchiectasis (large airways) End inspiratory = PF (small airways)
87
What might an inhaler at the bedside suggest
Asthma COPD (Bronchiectasis)
88
What are the main indications for pneumonectomy
1. Malignancy 2. Trauma 3. Chronic infection eg TB
89
What are the complications of lung transplant
Acute: rejection, opportunistic infection Chronic: rejection, Bronchiolitis obliterans, malignancy, side effects of immunosuppression
90
What are the contraindications to lung transplant
- malignancy in last 5 years - smoking/drug abuse - burkholderia/mycobacterium in CF - irreversible organ failure - acute illness - serious psychological illnesses
91
You have found a lung mass on CT that is suspicious for cancer, what is the next step
Obtain a tissue sample for diagnosis
92
How can a tissue diagnosis be obtained for a suspected lung cancer
- bronchoscopy - CT-guided biopsy - endobronchial US - lymph node biopsy - aspiration of pleural effusions
93
Which NSCLC is most commonly seen in smokers
Squamous cell (Look for thoracotomy + tar staining, evidence of COPD)
94
What are the differentials of a thoracotomy scar with a normal underlying lung and no tracheal deviation
- lobectomy - bullectomy - lung transplant - wedge resection - open lung biopsy - trauma
95
What indicates an educative pleural effusion on pleural fluid analysis
Protein >30g/L Using lights criteria: - pleural protein >0.5 of serum - pleural LDH >0.6 of serum - pleural LDH >2/3 UL of normal

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