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Respiratory Flashcards

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1
Q

When do we use Light’s criteria?

A

When want to see if pleural effusion is a transudate or exudate.

Pleural protein between 25-35g/L

If < 30 = transudate
if > 30 = exudate

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2
Q

Outline Light’s Criteria

A

Pleural protein : serum protein ratio > 0.5

Pleural LDH : Serum LDH ratio > 0.6

Pleural LDH > 2/3 ULN of serum LDH

Need only one of these to fulfil criteria

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3
Q

Give some differentials for unilateral reduced chest expansion and reduced percussion note

A

Pleural effusion
Pneumonia
Atelectasis
Pulmonary oedema
Raised hemidiaphragm
Lobectomy
Pleural thickening e.g. pleural plaques

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4
Q

What clinical features may you expect on clinical examination of a patient with a pleural effusion?

A

Scars/biopsy/chest drain/ radiotherapy tattoos

Clubbing/cachexia

o2 requirement/ resp distress

Reduced expansion
Trachea deviated away from side of effusion
Stony dull percussion note
Decreased vocal resonance
Reduced air entry/breath sounds
Reduced vocal fremitus

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5
Q

Clinical signs that indicate malignancy as underlying cause

A

Clubbing
Cachexia
Tar staining
Scars
Radiotherapy tattoos
Lymphadenopathy
Small muscle wasting of hand
Horner’s

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6
Q

Yellow nail syndrome features

A

Yellow nails
Lymphoedema
Bronchiectasis
Pleural effusion

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7
Q

Causes of transudative pleural effusion

A

CCF
Cirrhosis
Nephrotic syndrome
Hypoalbuminaemia (CLD, nephrotic syndrome, malabsorption)
Meig’s
Myxoedema

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7
Q

Causes of exudative pleural effusion

A

Malignancy (primary bronchial/ pleural / malignant)
Infection: parapneumonic, TB effusion
PE
sarcoid
CTD: RA, SLE, Sclerosis
Yellow nail syndrome
Pancreatitis

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8
Q

What should you do if pH < 7.2 on pleural tap?

A

Insert a chest drain

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9
Q

What is a downfall of Light’s criteria?

A

High false negative rate

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10
Q

What can you use instead of Light’s criteria?

A

Serum albumin pleural gradient (serum albumin - pleural albumin), for exudate should be < 1.2g/dL

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11
Q

Investigations for pleural effusion

A

Obs
Urine dip - proteinuria
ABG
ECG
Sputum MCS
Bloods: FBC, UE, LFT (albumin), CRP, TFT, LDH, Coag, ANA/ESR/ANCA/complement if autoimmune

Imaging
- CXR
- USS
- CT with contrast

Pleural aspiration with USS guidance

Invasive: percutaneous pleural biopsy, bronchoscpy, thoracoscopy

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12
Q

When would you insert a chest drain for pleural effusion?

A

pH < 7.2
Turbid pleural fluid
Positive MC&S + gram stain

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13
Q

What do you send the pleural fluid for?

A

pH
Protein
LDH
Glucose (v low in RA)
Cytology
Gram stain, MCS
Microbiology / AFBW

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14
Q

When would you get a pleural amylase?

A

If suspecting pancreatitisWh

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15
Q

when would you get a pleural triglycerides?

A

If expecting chylothorax

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16
Q

What are some ddx for a white out on CXR?

A

Pleural effusion (away)
Pneumonectomy (towards)
Complete lung collapse (Towards)
Massive mass (Trachea away)

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17
Q

Mx options for recurrent pleural effusions?

A

Indwelling pleural catheter
Medical/surgical pleurodesis

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18
Q

What is Meig’s syndrome?

A

Right sided pleural effusion associated with ovarian fibroma

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19
Q

Exudative causes of pleural effusion

A

Malignancy
- Primary bronchial
- Mets
- Pleural (mesothelioma)

Infection
- Parapneumonic
- Emypema
- TB

Inflammatory
- RA
- Sarcoid
- SLE

PE

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20
Q

Significant negatives on clinical examination of a patient with pleural effusion

A

Fever
o2 requirement
Cancer features (clubbing, cachexia, radiotherapy scar)
Raised JVP and peripheral oedema (CCF)
Liver failure signs (leukonychia, spider naevi, gynaecomastia, clubbing)
CTD signs

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21
Q

What are general peripheral signs in pulmonary fibrosis?

A

Clubbing, cushingoid features, tachypnoea, central cyanosis.

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22
Q

What are signs of RA on peripheral inspection in PF?

A

Rheumatoid hands, nodules.

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23
Q

What are signs of systemic sclerosis in PF?

A

Sclerodactyly, calcinosis, microstomia, beak nose, telangiectasia.

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24
What are chest findings in PF?
Thoracotomy scar +/- tracheal shift, fine end-inspiratory crackles.
25
What extra finding is associated with severe PF?
Cor pulmonale.
26
What are significant negatives in PF exam?
No cyanosis, no cor pulmonale, no signs of specific cause.
27
What are differentials for PF?
Bronchiectasis, pulmonary oedema
28
What are upper lobe causes of PF?
ABPA, pneumoconiosis, EAA, TB. Ankylosing spondylitis
29
What are lower lobe causes of PF?
Sarcoidosis (mid zone), BANS ME drugs, asbestosis, IPF, rheumatologic diseases
30
What drugs cause PF? (BANS ME)
Bleomycin, Amiodarone, Nitrofurantoin, Sulfasalazine, Methotrexate.
31
What bedside investigations are useful in PF?
PEFR, ABG, ECG (RVH).
32
What blood tests are relevant in PF?
FBC, UE, LFT, ESR, CRP, ANA, RF, ACE, Ca2+, etc.
33
What imaging findings support PF?
CXR: reticulonodular shadowing, low lung volume; HRCT: fibrosis, honeycomb lung.
34
What spirometry findings indicate PF?
↓TLC, ↓RV, ↓FEV, ↓FVC, FEV1:FVC > 0.8, ↓transfer factor.
35
What is the MDT in PF management?
GP, pulmonologist, physio, psych, palliative care, nurses, dietitian
36
What supportive care is used in PF?
Stop smoking, pulmonary rehab, vaccinations, LTOT
37
What is the only cure for IPF?
Lung transplant.
38
What is the 5-year survival for IPF?
50%.
39
What are specific treatments for EAA, sarcoid, and CTD-related PF?
Steroids.
40
What are the typical symptoms of interstitial lung disease?
Dry cough, SOB (esp. on exertion), leg swelling.
41
What key history points should be taken in ILD assessment?
Occupation, hobbies, current/past drug use.
42
What are the key examination findings in ILD?
Clubbing, signs of steroid use, central cyanosis, fine end-inspiratory crackles.
43
What signs suggest pulmonary hypertension in ILD?
Raised JVP, left parasternal heave, loud P2
44
What connective tissue diseases are linked with pulmonary fibrosis?
RA, SLE, systemic sclerosis, polymyositis, dermatomyositis, Sjogren’s, MCTD, ankylosing spondylitis.
45
What are examples of pneumoconiosis?
Asbestosis, coal workers’, silicosis, beryliosis
46
What is extrinsic allergic alveolitis (EAA)? (Same as HP)
Alveolar inflammation from hypersensitivity to organic inhalants.
47
Name causes of EAA (HP).
Bird fancier’s lung, farmer’s lung, cheese washer’s lung, hot tub lung, malt worker’s lung, miller’s lung, wood worker’s lung.
48
What does spirometry show in ILD?
Restrictive pattern with decreased gas transfer.
49
What is the general approach to treatment of PF?
MDT, oxygen, treat infections, reduce exposure.
50
What medications are used in non-IPF fibrosis?
Steroids, azathioprine, cyclophosphamide.
51
Is there disease-modifying treatment for IPF?
No – only supportive and palliative care.
52
When is lung transplant considered in PF?
Rarely – in severe, progressive disease.
53
What should patients with occupational ILD be informed about?
Occupational health compensation.
54
ILD + pacemaker?/ discoloured slate grey skin
Amiodarone
55
Unilateral fine end inspiratory crackles and contralateral throacotomy scar with normal breath sounds
Single lung tx in patient with ILD
56
What happens to the TLC, TLCO and KCO in ILD?
All reduced
57
Broad mx options for ILD
Immunosuppression Referral to NHSE Recognised ILD MDT if IPF for consideration of anti-fibrotics Single lung transplant
58
DDx posterolateral thoracotomy scar
Pneumonectomy Lobectomy Open lung biopsy Lung volume reduction surgery Single lung transplant Pleurectomy Bullectomy
59
Indications for lobectomy and pneumonectomy
Lung cancer (NSCLC) Infection: aspergilloma, TB, abscess Solitary pulmonary nodule Localised bronchiectasis Uncontrollable haemoptysis in bronchiectasis ILD Lung volume reduction surgery in COPD
60
Lung transplant scars
Clamshell Posterolateral thoracotomy (in single lung tx)
61
Most common indications for lung tx
Obstructive: COPD, a1at deficiency Restrictive: ILD Suppurative lung diseases: ie bronchiectasis, CF Vascular: Pulmonary HTN
62
Apex in pneumonectomy
Shifted towards side of pneumonectomy
63
What could clubbing indicate in a patient with a lobectomy/pneumonectomy
Malignancy ILD Bronchiectasis
64
DDx reduced breath sounds and tracheal deviation
Pneumonectomy Lung collapse Pneumothorax Pleural effusion (Expect trachea to be deviated away)
65
Clinical features if suspecting lung ca
Clubbing Cachexia Tar staining Wasting of small muscles of hand Horner's Radiotherapy tattoos Lymphadenopathy
66
Pre-transplant lung function testing requirements
Lobectomy: FEV1 > 1.5L Pneumonectomy FEV 1> 2L VO2 Max > 15ml/kg/min
67
important negatives in surgical resp case
Clubbing Cachexia Radiotherapy scars Tracheal deviation Chest expansion, breath sounds signs of underlying aetiology i.e. creps, crackles, prolonged expiratory wheeze, horner's/small muscle wasting, pulm HTN
68
Criteria for lung surgery
FEV 1 > 1.5 VO2 max > 15ml/kg/min no mets good WHO performance status no pulm HTN
69
Midline sternotomy in a resp station
Heart and lung transplant for pulm HTN, Eisenmenger's (congenital heart disease) , CF
70
Complications of a lung transplant
Rejection: including bronchiolitis obliterans syndrome Infection: CMV, HSV, PCP, aspergillus Immunosuppression complications
71
VATS procedure indications
Lobectomy Pleurodesis Bullectomy Decortication Pleural biopsy Lung biopsy Lung volume reduction surgery
72
Reduced lung expansion in lung ca DDx
Pneumonectomy Lobectomy Large mass Pleural effusion Lobar collapse
73
Ix in suspected lung ca
Bedside: History Obs Sputum MC&S ABG Lung function tests Bloods FBC, UE, LFT, Bone profile, coagulation Imaging: CXR Staging CT CAP Tissue diagnosis: Pleural tap if effusion Bronchoscopy EBUS Lung biopsy Lymph node biopsy Immunostaining for immunotherapy markers Pre-op: spirometry to assess fitness
74
Lung ca management:
Lung MDT: Radiologist, resp, resp CNS, cancer CNS, macmillan support groups, GP, psychologist Medical: radiotherapy, chemotherapy, immunotherapy, LTOT Surgical: wedge resection, lobectomy, pneumonectomy
75
Typical features of squamous cell ca
Central, cavitating lesion Smokers
76
Squamous cell cancer paraneoplastic syndromes
Hyperthyroidism (ectopic TSH) Hypercalcaemia (PTH secretion and bony mets)
77
Adenocarcinoma features
Peripheral, solid cancers non-smokers
78
Adenocarcinoma paraneoplastic features
HPOA
79
Hypercalcaemia in lung ca
Bony mets or paraneoplastic from ectopic pTH secretion in squamous cell cancer
80
Small cell lung ca paraneoplastic features
LEMS HPOA Ectopic ACTH SIADH
81
Lung cancer risk factors
Smoking Asbestos exposure Occupational exposure - beryllium ILD Radioactivity exposure ie uranium
82

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