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Respiratory Flashcards

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1
Q

What procedures can be performed in a VATS

A
  • Lobectomy
  • Bullectomy
  • Lung volume reduction surgery
  • Wedge resection
  • Decortication e.g. mesothelioma
  • Pleurectomy (treatment of recurrent pneumothoraces)
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2
Q

Types of lung Ca

A
  • Small cell lung cancer (usually presents late)
  • Non-small cell lung cancer
    • Squamous cell Ca
    • Adenocarcinoma
    • Bronchial Ca
    • Large cell
    • Neuroendocrine
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3
Q

Most common types of lung cancer

A
  1. Squamous cell cancer
  2. Adenocarcinoma
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4
Q

Indications for lobectomy/pneumonetomy

A
  • Lung cancer (almost always non-small cell lung Ca)
  • Infection e.g. TB, aspergilloma, ung abscesses
  • Pulmonary nodules
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5
Q

Indications for lung transplant

A

Bronchiectasis
Cystic fibrosis
COPD
Pulmonary fibrosis

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6
Q

Contraindications to lung resection in lung Ca

A
  • Reduced FEV1 (<1.5L)
  • Obstructed SVC
  • Paralysis of vocal cords
  • Effusion (malignant)
  • Distal mets
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7
Q

Asthma investigations

A

Bedside:
- SaO2
- PEFR
- ABG if acutely hypoxic

Bloods:
- FBC - eosinophilia, raised IgE
- Inflammatory markers

Imaging:
- CXR

Other tests:
- Peak flow diary
- Spirometry (obstructive)
- FEV1:FVC > 0.7 with bronchodilator reversibility in FEV1 of 12% or 200ml
- FeNO > 40 parts per billion
- Allergen testing

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8
Q

Investigations in asthma

A

Obstructive picture:
Reduced FEV1 with preserved FVC
Reduced FEV1:FVC ratio (<0.7)

FeNO (fractional exhaled nitric oxide) of >40 parts per billion

Reversibility with bronchodilators (FEV1 >12% and >200ml)

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9
Q

Spirometry in COPD

A

Obstructive picture:
Reduced FEV1 with preserved FVC
Reduced FEV1:FVC ratio (<0.7)

No reversibility with bronchodilator

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10
Q

Causes of obstructive lung disease

A
  • Asthma
  • COPD
  • Bronchiectasis
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11
Q

Asthma management

A

1) SABA PRN

2) SABA + ICS

3) SABA + ICS + [LTRA or LABA]

4) Specialist drugs e.g. theophylline

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12
Q

Causes of wheeze

A

Polyphonic:
- COPD
- Asthma
- Bronchiectasis

Monophonic:
- Cardiac wheeze secondary to pulmonary oedema

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13
Q

Causes of bibasal creps

A

Coarse:
- Bronchiectasis
- Bilateral pneumonia

Fine:
- Interstitial lung disease
- Pulmonary oedema

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14
Q

Investigations for Interstitial lung disease

A
  • Full history incl. drug history
  • Obs, especially SaO2 at rest and on exertion
  • ABG if newly hypoxic

Bloods:
- FBC, infection markers
- Autoimmune screen

Imaging:
- CXR
- HRCT

Special tests:
- Spirometry: reduced FEV1 and FVC with normal ratio, reduced transfer factor and reduced TLC
- Echocardiogram for pulm. HTN

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15
Q

Features of ILD on CT

A

Honeycombing
Ground glass shadowing

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16
Q

Management of ILD

A
  • MDT approach
  • Remove causative agent e.g. drug where possible
  • Pulmonary rehab
  • Home oxygen if needed
  • Idiopathic fibrosis: consider anti-fibrotic agent if FVC <80% predicted
  • Consider lung transplant
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17
Q

Anti-fibrotic agents in idiopathic pulmonary fibrosis

A

Pirfenidone
Nintedanib

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18
Q

Causes of interstitial lung disease

A

Idiopathic pulmonary fibrosis

Connective tissue disease:
- SLE
- Systemic sclerosis
- Rheumatoid arthritis

Drugs: amiodarone, methotrexate

Exposure to fibrotic agents:
- Asbestosis
- Silicon

Extrinisic allergic alveolitis (asthma + ILD)
- Bird fanciers lung
- Farmer’s lung

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19
Q

When would you consider an anti fibrotic agent in IPF?

A

FVC <80% predicted
- refer to teritary centre for consideration of pirfenidone or nintenadib.

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19
Q

Cystic fibrosis - possible extrapulmonary features on examination

A
  • CBG monitor
  • Gastrostomy tube for feeding
  • Liver transplant
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19
Q

What does sweat test show in cystic fibrosis?

A

Excess chloride in sweat

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19
Q

Cystic fibrosis pathophysiology

A
  • Autosomal recessive
  • Mutation in CFTR gene
  • Increased salt excretion results in sticky, viscous secretions which are difficult to clear
  • Multisystem disease
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19
Q

Microbiology in cystic fibrosis

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A

Most common: pseudomonas aeruginosa

Poor prognosis: Burkholderia
- this is an absolute contraindication to lung transplantation

19
Q

Complications of cystic fibrosis

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A

Lungs:
- Bronchiectasis
- Recurrent infections
- Increased risk pneumothorax
- Respiratory failure

Gastrointestinal:
- Pancreatic insufficiency -> malnutrition, diabetes
- Gallstones
- Liver dysfunction

Metabolic:
- Osteoporosis

Reproductive:
- Reduced fertility

Psychological effects

19
Management of cystic fibrosis
MDT approach in specialist centre Chest: - Regular physiotherapy - Cough assist devices - Mucolytics - Antibiotic prophylaxis (nebulised Abx + oral azithromycin) GI: - Pancreatic insufficiency: Creon, fat-soluble vitamins - Nutritional support Psychological support Some go on to lung transplant
19
Features of cystic fibrosis examination
- Clubbing - Coarse inspiratory crackles - May be malnourished (pancreatic insufficiency + catabolic state) Check for: - Portacath or hickman line - Gastrostomy tube - Liver transplant scar
20
Causes of upper zone lung fibrosis
PHARTS Pneumoconiosis Histiocytosis Ank. spondylitis Radiation TB Silicosis
21
Causes of lower zone fibrosis
RAID Rheumatoid arthritis Asbestosis Idiopathic pulmonary fibrosis Drugs e.g. methotrexate, amiodarone
22
Examination findings in pneumonectomy versus lobectomy
Pneumonectomy: - Tracheal deviation - Absent or bronchial breath sounds - Dull percussion Lobectomy: - Trachea central or mildly deviated - Normal or reduced breath sounds - Normal percussion
23
Respiratory causes of clubbing
- Interstitial lung disease (IPF) - Chronic suppurative lung disease - bronchiectasis, cystic fibrosis - Lung cancer
24
Which lung cancer is most strongly associated with smoking?
Squamous cell carcinoma in Smokers
25
COPD management
1) SABA (salbumtaol) or SAMA (iptratropium) 2) Add a LABA (salmeterol) and either: - ICS (if steroid responsive) - LAMA e.g. tiotropium (if not steroid responsive) 3) LABA + LAMA + ICS
26
Investigations in suspected lung Ca
Imaging: - CXR - CT Chest - Staging CT CAP Tissue diagnosis: can be done via - Bronchoscopy - EBUS with transbronchial needle aspiration) - CT-guided biopsy Spirometry - helps guide management Bloods incl. Na (SIADH) and Ca (hyperCa of malignancy)
27
Lung function tests pre-operatively
Lobectomy: FEV1 > 1.5L Pneumonectomy: FEV1 >2L
28
Indications for lung transplant
- COPD is the most common (usually single) - Cystic fibrosis - Bronchiectasis - Pulmonary fibrosis - Pulmonary vascular disease
29
Immunosuppression after lung transplant
Typically calcineurin inhibitor (tacrolimus or ciclosporin), mycophenalate and prednisolone
30
Complications after lung transplant
Acutely: - Graft rejection - Opportunistic infections (bacterial, mycobacterial, fungal) Longer term: 1) Bronchiolitis obliterans (usually a terminal event) - leading cause of death after 1 year 2) Malignancies - PTLD (post transplant lymphoproliferative disease) - Skin malignancies 3) Adverse effects from medications - Metabolic complications e.g. diabetes - Renal impairment
31
Contraindications to lung transplant
Absolute contraindications: - Malignancy in last 5 years - Current smokers - Recreational drug use - Low probability of engaging with post-transplant care e.g. severe cognitive dysfunction or mental health Relative contraindications: - Age >65 - BMI >30 or malnutrition - Resistant organism colonisation e.g. Burkholderia
32
Criteria for lung transplant
1) >50% risk of death from lung disease if transplant is not performed 2) >80% likelihood of surviving 90 days post transplant 3) >80% likelihood of 5-year post-transplant survival
33
When do you do double versus single lung transplant
Double = suppurative lung disease - Cystic fibrosis - Bronchiectasis Single lung transplant - COPD - Interstitial lung disease
34
Best and worst lung transplant prognosis
Cystic fibrosis = best Pulmonary fibrosis = worst
35
Causes of bronchiectasis
1) Recurrent infections: - Recurrent childhood infections e.g. measles, pertussis - Recurrent aspiration pneumonia - Immunodeficiencies: primary (hypogammaglobulinaemia), secondary (HIV) 2) Congenital disease - Cystic fibrosis - Primary ciliary dyskinesia - Kartageners (would expect situs inversus) 3) Connective tissue disorders - Rheumatoid arthritis - SLE 4) ABPA - Allergic BronchoPulmonary Aspergillosis - Asthma + central bronchiectasis (triggered by aspergillus mould)
36
Restrictive lung function tests - how to differentiation fibrosis versus mechanical restriction
Mechanical: normal transfer factor Fibrosis: reduced transfer factor
37
Causes of unilateral/localised bronchiectasis
- Localised infection e.g. TB - Granuloma e.g. sarcoidosis - Foreign body - Bronchial carcinoma
38
Respiratory causes of clubbing
ABC-EF Abscess/Asbestosis Bronchiectasis/Bronchial Ca Cystic fibrosis Extrinsic allergic alveolitis Fibrosis idiopathic
39
Respiratory causes of clubbing and crackles
FABB Fibrosis idiopathic Asbestosis Bronchiectasis Bronchial ca
40
Management of bronchiectasis
1) EDUCATION: - Smoking cessation - Vaccinations 2) CAUSE: identify and treat if possible 3) MUCUS CLEARANCE: - Chest physio - Mucolytics eg carbocisteine - Cough assist devices 4) ANTIBIOTICS: - Must take sputum samples - 2/52 targeted course Abx - usually nebulised specific to patients colonisation - If >2 chest infections per year despite this - prophylaxis 5) NUTRITIONAL SUPPORT: dietitian review
41
Complications of bronchiectasis
- Lungs: abscesses, pneumothorax - Malnutrition - Respiratory failure
42
Pleural effusion mimics/DDx
1) Raised hemidiaphragm - Lobar collapse - Phrenic nerve palsy 2) Pleural thickening e.g. mesothelioma 3) Consolidation e.g. pneumonia 4) Mass lesion e.g. malignnacy
43
Light's criteria for pleural effusion
Exudative if one of the following is met: 1) Pleural fluid protein divided by serum protein is >0.5 2) Pleural fluid LDH divided by serum LDH >0.6 3) Pleural fluid LDH is >2/3rds the upper normal limit of LDH
44
Features of life-threatening asthma
CCHESS 33 pCO2 normal/high - pCO2 becomes normal → acidotic; so acidosis also a life-threatening sign Confusion Hypotension Exhaustion Silent chest Sats <94% PEFR <33%
45
Acute asthma exacerbation management
Sit upright High-flow O2 B2B Salbutamol and Ipratropium nebs Steroids If PEFR not improving after nebs, consider salbutamol infusion + IV Mg (causes smooth muscle relaxation) Repeat ABGs - if pCO2 not improving despite treatment, discuss with ITU If life-threatening: intubate and ventilate
46
Most common lung Ca in non-smokers
adeNOcarcinoma in NON smokers
47
When would a pneumonectomy be performed rather than a lobectomy
Lung Ca - involving multiple lobes OR a central Ca not amenable to lobectomy Extensive unilateral bronchiectasis Extensive unilateral infection e.g. multiple lung abscess
48
Pneumothorax management
Primary PTX - <2cm and not short of breath: discharge - >2cm or short of breath: needle aspiration Secondary PTX - 0-1cm: Admit for observation, oxygen - 1-2cm or SOB: Needle aspiration - >2cm: chest drain
49

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