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Respiratory Flashcards

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1
Q

Contraindications for lung transplant in CF

A

Burkholderia cepacia colonised in sputum
Mycobacterium

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2
Q

Light’s criteria

A

Used if fluid protein 25-35

Pleural protein: serum protein >0.5
Pleural LDH: Serum LDH >0.6
Pleural LDH >2/3 ULN serum LDH

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3
Q

Indications for VATS

A

Pleural or lung biopsy
Pleurodiesis
Pleurectomy
Empyema treatment
Pericardiocentesis

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4
Q

Mutations in CF

A

Mutations in CFTR excretion - more salt excretion in mucus
Most common deltaF508

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5
Q

Specific treatment for deltaF508

A

Ivacaftor and Orkambi

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6
Q

Surgical treatment in COPD

A

Lung reduction surgery
Lung transplant

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7
Q

Indications for LTOT in COPD

A

Pa02 <8kpa with evidence of pulmonary hypertension, polycythaemia or peripheral oedema

Pa02 <7.3kPa

No smoking in household

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8
Q

Long term treatment in COPD

A

Smoking Cessation
Pulmonary rehab
Vaccinations - flu/COVID/pneumococcal
Inhaler therapy - LABA/LAMA or adding ICS if eosinophilia or repeated infections
LTOT

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9
Q

Contraindications to NIV

A

Capacitous refusal
Facial fractures
Oesophageal burns
Vomiting
Pneumothorax
Airway obstruction
Pneumothorax
Hypotension
Recent upper GI surgery

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10
Q

Spirometry values in COPD

A

Diagnosis - FEV1/FVC <70%

Mild >80%
Moderate - FEV1 50 - 80%
Severe - FEV1 30-50%
Very evere - <30%

Increased residual volume
Decreased TLCO

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11
Q

Investigations in new COPD

A

FBC - anaemia, polycythaemia and eosinophilia
IGE to aspergillus and dog/cat dander
A1AT deficiency if young
ABG

CXR
CT - emphysema and bulls lung disease

Spirometry with reversibility testing

ECHO if concerns re PHTN

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12
Q

Differential diagnoses for COPD

A

Asthma
EGPA
A1AT

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13
Q

Signs of pulmonary hypertension

A

Raised JVP
Pulsatile liver
Loud second heart sound
Pedal oedema
Tricuspid regurgitation

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14
Q

Clinical findings in COPD on inspection

A

Barrel Chested
Tar staining
Pursed lips
Tremor
Central cyanosis
Raised JVP in cor pulmonate

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15
Q

Signs in bronchiectasis

A

Wet cough
Clubbing
Long lines and central access
Cachexia
Scars from previous lines or lung surgery
Clamshell scar under the ribcage
Deviated apex beat and loud P2
Wet coarse crackles at bases - change with coughing

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16
Q

Presentation in bronchiectasis

A

Signs of right sided heart failure - raised JVP, pedal oedema, loud P2
Signs of treatment - neb or iv antibiotics
Scars from lung transplant
Possible etiology

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17
Q

Causes of bronchiectasis

A

Congenital
- Kartageners - dextracardia
- CF

Yellow nail syndrome

Post infectious eg tb, childhood pneumonias (pertussis)

Autoimmune
- RA
- lupus
- sjogrens
- IBD

Immunodeficiencies:
- Hypogamma globulinaemia
- CVID
- HIV

ABPA

Aspiration - chronic alcoholics, post stroke

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18
Q

Ix in bronchiectasis

A

CXR - tramlines and ring shadows

HRCT - signet rings, tram lines, tree in bud appearance, inner lumen bigger than adjacent blood vessel

Bloods
- HIV test
- Autoimmune screen
- Immunoglobulin
- IgE aspergillus
- eosinophilia

Sputum samples

Sweat test and ciliary biopsy in CF

Saccharine motility tes

Lung function tests
- Reduced FEV1 - obstructive due to inflamed or scarred airways

Echo if concerns re pulmonary hypertension

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19
Q

Mx in bronchiectasis

A

MDT
Patient education
Identify cause
Chest physio - postural chest drainage
Hypertonic saline nebs
Targeted antibiotic therapy
Carbocisteine
Opep device - flutters and breaks up mucus
Immunization
Dietician
Prophylaxis antibiotics
- if having more than two chest infections which have been fully treated
- dependent on sensitivities
- may be oral or nebulised (eg PO azithromycin or Neb tobramycin)

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20
Q

Ix in ILD

A

Bedside test inc SpO2

Bloods including Rhf, anti-CCP, ANA, ANCA, dsDNA

ABG

CXR

HRCT
- Honeycombing - fibrosis
- Ground glass shadowing - alveoli’s

ECHO - signs of pulmonary hypertension

Spirometry

Potential biopsy - unclear diagnosis - via bronchoscopy or trans lung

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21
Q

Spirometry findings in ILD

A

Restrictive pattern
Decrease in FEV1 and FVC with preserved ratio
Reduced TLC
Decrease in transfer factor

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22
Q

MX of ILD

A

MDT
Resp nurses
PT and OT
Treatment of underlying CTD
Steroids
Idiopathic ILD - anti-fibrotic agents
- Pirfenedone or ninetenib - its with a FVC 50-80% to slow disease progression
NSIP - steroids and immunosuppressive therapy
Lung transplant

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23
Q

Causes of ILD

A

Idiopathic
RA
SLE
Asbestosis
Drugs - bleomycin, amiodarone, MTX, nitrofurantoin
AS
Radiation
Coal workers pneumoconiosis
Silicosis
EAA
Sarcoidosis
TB

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24
Q

Features in CF

A

Increased and thickened respiratory secretions
Pancreatic insufficiency
Decrease in fertility
Liver disease - portal HTN
Osteopenia
Nasal polyps
Distal intestinal obstruction syndrome
Gallstones and kidney stones

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25
Management in CF
MDT in specialist centre Chest physio Nebulised hypertonic saline Mucolytics Nebulised prophylactic antibiotics Creon Dietician Nutritional supplementation Treatment of infection with 2 week course of antibiotics Fat soluble vitamin supplementation Immunisations
26
Diagnosis of CF
Screening with Guthrie test Episode of meconium ileus Sweat test Genetic testing
27
Commonest indicator conditions for lung transplantation
CF Bronchiectasis ILD Pulmonary vascular disease COPD
28
Double vs single lung transplant
Prognosis better with double lung transplant - 7.5 vs 4 years
29
Medications used in lung transplantation
Combination of tacrolimus, MMF and steroids
30
Complications of lung transplant
Hyperacute/acute rejection Opportunistic infections Brochiolitis obliterates - chronic rejection - 50% at 5 years Increased risk of malignancy including post transplant lymphoproliferative disease and skin malignancies
31
Contraindications to lung transplantation
Malignancies within last 5 years Untreatable heart, brain or liver dysfunction that won't be treated with transplant Untreated atherosclerotic disease or CAD not amenable to revascularisation High or low BMIs Using illicit drugs or smoking Mental health issues which would stop them taking regular meds or turning up to clinic appts Virilent lung pathogens including Burkholderia cepacia or mycobacterium
32
Indications for single lung transplant
COPD ILD
33
Indications for lung transplant
>50% risk of death from lung condition within 2 years without transplant >80% chance of survival 90 days post transplant >80% chance of 5 year survival from general medical viewpoint
34
Indications in CF for lung transplant
FEV1 <30% Significant pHTN Poor exercise tolerance High exacerbation frequency Frequent PTXs Haemoptysis despite pulmonary artery embolisation NIV
35
Indications in ILD of lung transplant
Due to poor prognosis - fibrotic NSIP with no contraindications should be considered FVC <80% Transfer factor <40% Any oxygen requirement or symptomatic dyspnoea
36
Scores for high risk vs low risk PE treatment
PESI or sPESI - Class I and II
37
Anticoagulation treatment for PE
Provoked PE - 3 months Unprovoked - 3-6 months
38
Management of unstable PE patients with contraindication for thrombolysis
Surgical vs mechanical thrombectomy
39
Methods of gaining a lung biopsy
Bronchoscopy EBUS Percutaneous LN FNA Pleural aspirate cytology
40
Different types of lung cancer
Small cell and NSCLC NSCLC - SCC, adenocarcinoma, large cell tumours, neuroendocrine, and bronchoalveolar
41
Treatment of SCLC
Usually aren't amenable to surgery at diagnosis - aggressive Chemotherapy regimens - platinum based with radiotherapy +/- adjuvant brain radiation in limited disease
42
Treatment of NSCLC
Surgery or radical radiotherapy (stage I and II disease) Chemotherapy/immunotherapy TKI - e.g erlotinib (EGFR) or alectinib (ALK)
43
Clinical signs in lung cancer
Finger clubbing - HPOA Wasting of small muscles in hand Cachexia Hoarseness of voice Tar staining Horner syndrome - ptosis, miosis and facial swelling Dilated chest wall veins and facial swelling Radiotherapy tattoos VATS scars Thoracotomy scar Reduced expansion or reduced air entry if collapse or surgical excision Tracheal deviation - away from pleural effusion, towards collapse Lymphadenopathy
44
Causes of pleural effusions
Exudative effusions: - Parapneumonic - Tb - Empyemas - Malignancy - CTD e.g. RA and sarcoid Transudative: - HF - Liver failure - Chronic kidney disease - Hypoalbuminaemia - Hypothyroidism
45
Pleural aspirate sendaways
Protein LDH pH Culture Cell count Cytology Glucose - if ?RA Triglyceride - if suspected chylous
46
Pleural effusion treatment
Drainage indicated if pH <7.2, frank pus or positive cultures If not symptomatic management and drainage only if needed If due to underlying malignancy can have an indwelling drain or pleurodiesis
47
Ix in pleural effusions
FBC, U&Es, LFTs, Ca, Coag CXR Pleural samples CT thorax with contrast Pleural biopsy - medical thoracoscopy
48
Indications for lung surgery in lung cancer
Stage I or II disease, or selected stage III disease without mediastinal lymph node involvement Lobectomy: - FEV1 >1.5L Pneumonectomy: - FEV1 >2L Will also need CPET - 15ml/kg/min
49
Indications of thoracotomy
LL/UL lobectomy Pneumonectomy Wedge resection Open lung biopsy Bullectomy Previous trauma
50
Indications for lobectomy/pneumonectomy
Malignancy - NSCLC or malignant nodule Lung Abscess Localised bronchiectasis TB Lung trauma
51
Indications for VATS
Lung biopsy Pleural procedures Lobectomy
52
Mechanism of cor pulmonae in COPD
Chronic hypoxia Pulmonary vasoconstriction Pulmonary hypertension Right side cardiac failure
53
Causes of apical pulmonary fibrosis
Tb Radiation Ankylosing spondylitis/ABPA Sarcoidosis Histoplasmosis/histiocytosis/pneumonitis Coal worker's pneumoconiosis Berylliosis Silicosis
54
Side effects of Tb medications
Isoniazid - peripheral neuropathy (co-prescribe pyridoxine) Rifampicin - Hepatitis and enzyme induced (careful of COCP) Ethambutol - retrobulbar neuritis and hepatitis Pyrazinamide - hepatitis
55
Clinical differences between lobectomy and pnuemonectomy
Lobectomy: - Breath sounds present - May have some dullness to percussion or hyper resonance at base or apex depending on which lobe was resected - Trachea central Pneumonectomy: - Breath sounds absent (may have bronchial breathing at apex) - Dull percussion note throughout hemithorax - Trachea pushed towards side of pneumonectomy
56
Indications for single lung transplant
COPD, ILD (Dry conditions) Thoracotomy scar, may have clinical signs on opposite hemithorax
57
Indications for double lung transplant
Bronchiectasis (including CF), pulmonary hypertension Clamshell scar
58
Classification of severity in COPD
Classified by GOLD framework using FEV1 Mild - >80% Mod - 50-80% Severe - 30-50% Very severe - <30%
59
Differentials for wheeze on auscultation
COPD - Smoking/industrial - A1AT Asthma GPA Obliterative bronchiolitis - seen in RA and in post transplant lung
60
Surgical treatments in COPD
Bullectomy - if bulla >1L and causing compression on surrounding lung Endobronchial valve Lung reduction surgery Lung transplant - usually single
61
Spirometry findings in COPD
Reduced FEV1 FEV1:FVC ration <0.7 Reduced TLCO
62
Causes of pleural effusions
Trasnudative (<30g/L protein): - CCF - Cardiac failure - Chronic liver failure Exudative >30g/L protein; - Infection either parapneumonic or empyema - Cancer - Inflammatory condiitons e.g. RA, SLE - Pulmonary infarction
63
Causes of a dull lung base
Pleural effusion Consolidation in infection Raised hemidiaphragm Lobectomy Pleural thickening
64
Complications seen in lung cancer
SVCO - Bronchial cancers causing facial swelling and dilated chest veins Hypercalcamia - mostly commonly in SCC (secretion of PTHrp or in mets) Recurrent laryngeal nerve palsy Horner's syndrome - seen in Pancoast tumours MSCC Cushing's disease - Most commonly in SCLC - with ectopic ACTH secretion SAIDH - most commonly in SCLC Lambert-Eaton syndrome - most commonly in SCLC - VGCC abs presents Dermatomyositis - Gouttrons papule, heliotrope rash and raised CK
65
Types of lung cancer
SCLC - 25% NSCLC: - SCC - 35% - adenocarcinoma - 20% - Large cell - 20% - Alveolar
66
Additional tests for organisms in pneumonia
Legionella antigen (may also be hyponatraemic) Pneumococcal antigen Haemoglobinuria - mycoplasma causes cold agglutinins leading to haemolysis
67
Causes of CAP
Strep pneumonia Mycoplasma pneumonia Haemophilusinfluenza Chalmydia pneumonia Post influenza - S aureus Immunosuppressed; - Fungal - PCP - treat with co-trimoxazole
68
CURB65 score
Confusion Urea >7 Respiratory rate >30 BP <90 systolic or <60 diastolic >65 2/5 is severe and should receive IV abs
69
Complications of CAP
Parapneumonic effusion Empyema Haemoptysis Sepsis
70
Investigation of Pulmonary Hypertension
Bloods: - Autoimmune screen) - TFTs - Liver function (porto-pulmonary PH) - HIV CXR ECG ECHO - looking for right ventricular size and function, peak tricuspid regurgitant velocity to estimate pulmonary pressure CTPA - chronic thrombi PFTs Right heart catheterisation
71
Causes of Pulmonary Hypertension
Class I: Pulmonary arterial hypertension - idiopathic, heritable, CTD, congenital heart disease, portal hypertension, HIV Class II: Left heart disease: systolic or diastolic dysfunction or valvular disease Class III: Lung disease: COPD, ILD, obesity hypoventilation, sarcoidosis Group IV: Chronic thromboembolic disease Group V: miscellaneous - harm-dialysis, thyrotoxicosis
72
Treatment in Pulmonary Hypertension
Group 1 (PAH): - CCBs - nifedipine - only in those responsive to vasodilator challenge during right heart catheterisation - Phophodiesterase 5 inhibitors - sildenafil - Endothelin receptor antagonists - bosentan, ambrisentan - Prostaglandin analogues - epoprostenol (IV infusion) or Neb iloprost Double lung transplant Group 4 (chronic thromboembolic disease): - Life long anticoagulation - Pulmonary endarterectomy surgery if proximal If distal balloon pulmonary angioplasty Group 2,3, and 5 - treat underlying cause
73
Complications of Pulmonary Hypertension
Right heart failure Atrial arrhythmias Dilatation of the proximal pulmonary artery - stretching of the recurrent laryngeal nerve - voice hoarseness External compression of the the LAD - angina type symptoms and ventricular arrhythmias External compression of the RML bronchus - localised bronchiectasis

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