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Respiratory cases Flashcards

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1
Q

Consultation - what are the symptoms of asthma?

A

Wheeze, breathlessness, chest tightness and cough.
Symptoms worse at night and early morning, worse if exercising/cold air/allergen exposure.
Other atopy/family history of atopy.

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2
Q

What examination features would you expect to see in asthma?

A

Tachycardia from SABA.
May have a prolonged expiratory phase.
Widespread wheeze.
Low forced expiratory volume in one second or peak expiratory flow.

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3
Q

Given the findings of diffuse wheeze and prolonged expiratory phase, what is your preferred diagnosis and differentials?

A

Asthma
DDX:
COPD
Heart failure
Coronary heart disease
GORD

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4
Q

What is asthma?

A

Paroxysmal and reversible obstruction of the airways. Bronchospasm and excessive production of secretions.

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5
Q

What are the complications of asthma?

A

Pneumonia
Pneumothorax
Pneumomediastinum
Respiratory failure and arrest

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6
Q

How would you investigate for asthma?

A

Spirometry - airway obstruction with positive bronchodilator reversibility (normal spirometry if asymptomatic doesn’t rule out asthma).
Trial treatment for 6 weeks with a symptom questionnaire and parallel peak flows - if good improvement with treatment, it’s more likely.
Fractional exhaled nitrous oxide - measure nitric oxide which is increased in inflammation and asthma.
Chest X-ray - normal.

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7
Q

How would you manage a patient with asthma?

A

MDT approach - specialists (if very poor control) and GPs, asthma nurses.
Aims to control symptoms, prevent exacerbations, improve lung function, all with minimal side-effects.
Stepwise approach: SABA inhaler; add-on steroid inhaler; add-on leukotriene receptor antagonist then LABA (if not helping then stop and increase ICS dose); increase ICD and/or add-on further theophylline or beta agonist tablet; oral steroids.

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8
Q

What is the prognosis of asthma?

A

Can have good symptom control, people still die from asthma in the UK (1500 in 2017).

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9
Q

What examination features would you expect to see in bronchiectasis?

A

Early inspiratory coarse crackles in lower zones.
Large airway rhonchi.
Wheeze.
Clubbing (infrequent).

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10
Q

What is the prognosis of bronchiectasis?

A

90% of non-CF bronchiectasis 5 year survival
P. aueruginosa associated with disease progression in non-CF bronchiectasis.

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11
Q

Given the findings of early inspiratory coarse crackles, wet cough, and wheeze what is your preferred diagnosis and differentials?

A

Bronchiectasis caused by: post-infection, immunodeficiency, connective tissue disease, asthma, allergic bronchopulmonary aspergillosis, gastric aspiration.
DDx:
COPD
Asthma
TB
Chronic sinusitis
Postnasal drip (upper airway cough syndrome)
Cough due to GORD

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12
Q

Consultation - what are the symptoms of bronchiectasis?

A

Variable - intermittent episodes of expectoration and infection to persistent daily expectoration.
Nonspecific respiratory symptoms - dyspnoea, chest pain, haemoptysis.
Repeated infective exacerbations.

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13
Q

What is chronic obstructive pulmonary disease?

A

A heterogeneous lung condition with chronic respiratory symptoms due to abnormalities of the airways (bronchitis) and/or alveoli (emphysema) that causes persistent airflow obstruction.

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14
Q

How would you manage a patient with bronchiectasis?

A

Aim to avoid any further damage to the lungs.
MDT approach including regular follow up in secondary care, dietician for health diet, smoking cessation services if applicable, physiotherapy for airway clearance exercises.
Immunisation - influenza and pneumococcus.
Antibiotics for acute exacerbations +- long-term antibiotics.
Bronchodilators.
Oxygen therapy and NIV if chronic respiratory failure.
Lung resection if localised disease, lung transplant if end-stage disease.

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15
Q

What is bronchiectasis?

A

Permanent dilatation and thickening of the airways with chronic cough, excessive sputum production, bacterial colonisation and recurrent infections.

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16
Q

What examination features would you expect to see in chronic obstructive pulmonary disease?

A

Cachexia
Hyperinflated chest, pursed lip breathing, accessory muscle use, paradoxical movement of lower ribs, reduced cricosternal distances
Wheeze or quiet breath sounds
Reduced cardiac dullness on percussion
Peripheral oeema
Cyanosis
Raised jugular venous pressure

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17
Q

How would you investigate for bronchiectasis?

A

Sputum microbiology
Bloods - FBC for infection or polycythaemia if advanced, immune function tests (including IgG/A/M)
Cystic fibrosis testing if under age of 40
Lung function tests - annually
CXR - normal or opacities +- fluid levels.
HRCT - bronchial wall dilation
Bronchoscopy

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18
Q

What are the complications of bronchiectasis?

A

Repeated infections and worsening lung function.
Empyema or lung abscess.
Pneumothorax from repeated coughing.
Respiratory failure.
Reduced quality of life.

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19
Q

Consultation - what are the symptoms of chronic obstructive pulmonary disease?

A

Exertional breathlessness, chronic cough, regular sputum production, winter ‘bronchitis’, wheeze.
Presence of risks factors - smoking primarily.
Also ask about weight loss, effort intolerance, waking at night breathless, ankle swelling, fatigue, chest pain, haemoptysis - none of which are COPD related.
MRC dyspnoea scale: 0 - not breathless unless strenuous exercise; 1 - SOB when hurrying or walking up hill; 2 - walks slower than friends on the flat; 3 - SOB after 100m; 4 - breathless on getting dressed.

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20
Q

Given the findings of poor chest expansion, quiet breath sounds, pursed lip breathing, reduced cricosternal distance what is your preferred diagnosis and differentials?

A

COPD - caused by smoking tobacco, marijuana, air pollution, occupational exposure (dusts, fumes, chemicals).
DDx:
Asthma
Bronchiectasis
Congestive cardiac failure
Lung cancer

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21
Q

How would you investigate for chronic obstructive pulmonary disease?

A

Most important - spirometry - FEV1 <80% predicted and ratio FEV1/FVC <0.7.
Sputum culture
ECG and echo if pulmonary hypertension
Bloods - FBC for anaemia, polycythaemia.
CXR - exclude other pathologies.
CT thorax if not explained by spirometry.

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22
Q

How would you manage a patient with chronic obstructive pulmonary disease?

A

MDT approach - COPD nurses, smoking cessation clinics, physiotherapy, follow up.
Prognostic improving treatment: smoking cessation, pulmonary rehabilitation, long-term oxygen therapy or noninvasive ventilation, lung volume reduction surgery or lung transplant.
Inhalers - SABA, LAMA, LABA, SABA, ICS (triple therapy - LABA + LAMA + ICS).
Exacerbation - prednisolone 30mg for 5 days, antibiotics if suggestive of bacterial exacerbation (often 5 days of amoxicillin or doxycycline or clarithromycin), send sputum culture.

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23
Q

What are the complications of chronic obstructive pulmonary disease?

A

Chronic hypoxaemia can lead to pulmonary hypertension and sometimes cor pulmonale
Pneumothorax
Respiratory failure
Depression

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24
Q

What is the prognosis of chronic obstructive pulmonary disease?

A

Can use BODE index (BMI, airflow Obstruction, Dyspnoea, Exercise capacity) or just FEV1.
Variably progressive.

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25
Consultation - what are the symptoms of interstitial lung disease?
Dyspnoea, worsening exercise tolerance, dry cough, chest discomfort. General malaise and fatigue. May have connective tissue disease symptoms - arthralgia, difficulty swallowing, dry eyes.
26
What examination features would you expect to see in interstitial lung disease?
Bilateral fine end-inspiratory crepitations (velcro sounding). Can have pleural effusion with some connective tissue disease causes. Clubbing, particularly in idiopathic ILD. Signs of systemic disease.
27
Given the findings of fine bilateral inspiratory crepitations and clubbing what is your preferred diagnosis and differentials?
Idiopathic interstitial lung disease (includes idiopathic pulmonary fibrosis as most common type). DDx: ILD caused by: connective tissue disease (e.g. RA, SLE, systemic sclerosis); inhaled substances - silicosis, abestosis, hypersensitivity pneumonitis; drug-induced - methotrexate, amiodarone, bleomycin; infective - mycoplasma pneumonia, pneumocystic pneumonia. COPD Asthma Congestive cardiac failure Bronchiectasis
28
What is interstitial lung disease?
Inflammation and fibrosis in the lung interstitium. The lung interstitium becomes thicker and compromises gas exchange.
29
How would you manage a patient with interstitial lung disease?
MDT approach - smoking cessation services, pulmonary rehabilitation. Conservative - vaccinations (annual flu, one-off pneumococcal), LTOT if PaO2 <7.3 or <8 with peripheral oedema/polycythaemia/pulmonary hypertension. Medical - antifibrotics if idiopathic (nintedanb, pirfenidone), steroids for sarcoidosis or connective tissue disease or extrinsic allergic alveolitis. Surgical - lung transplant.
30
How would you investigate for interstitial lung disease?
Bedside - pulse oximetry, urine dip (haematuria/proteinuria may suggest vasculitis), lung function tests (restrictive pattern). Lab - FBC (anaemic of chronic disease), CRP and ESR (can be elevated), U+Es (deranged if vasculitis), autoimmune antibodies (if suspecting underlying systemic disease e.g. RA). Imaging - CXR (reticular opacities), high-resolution CT (honeycombing, traction bronchiectasis, reticular opacities). Invasive - broncheoalveolar lavage, biopsy.
31
What are the complications of interstitial lung disease?
Respiratory failure, pulmonary hypertension. Anxiety and depression. Long term steroids - osteoporosis, hypertension, Cushing's. Antifibrotics - diarrhoea, nausea, anorexia.
32
What is the prognosis of interstitial lung disease?
Median survival for idiopathic pulmonary fibrosis is 3.5 years. Lung transplant - 5 years for IPF or 7 years for other types. 3-fold increased risk of lung cancer with ILD.
33
Consultation - what are the symptoms of kyphoscoliosis?
Back pain, shortness of breath.
34
What is kyphoscoliosis?
Abnormal curvature of the spine in coronal and sagittal planes.
35
Given the findings of S and C shaped spine what is your preferred diagnosis and differentials?
Kyphoscoliosis - due to congenital abnormalities including spina bifida, infections e.g. TB, osteoporosis or osteoarthritis related, idiopathic.
36
How would you investigate for kyphoscoliosis?
Imaging. Underlying cause e.g. kyphoscoliotic Ehlers-Danlos syndrope is caused by mutation of the PLOD1 gene or FKBP14.
37
What examination features would you expect to see in kyphoscoliosis?
Abnormal curvature of the spine, can have an abnormal gait. Pulmonary hypertension.
38
How would you manage a patient with kyphoscoliosis?
MDT approach - physiotherapy. Back braces. Surgery.
39
What are the complications of kyphoscoliosis?
Respiratory failure - upper airway obstruction, obstructive disease, restrictive changes.
40
What is the prognosis of kyphoscoliosis?
Normal life expectancy usually.
41
Consultation - what are the symptoms of a lobectomy?
Pre-lobectomy - symptoms based on cause of need for lobectomy - chronic cough, haemoptysis, shortness of breath, weight loss. Post-lobectomy - symptoms of complications e.g. infection.
42
What examination features would you expect to see in a lobectomy?
Thoracotomy scar. VATS scars.
43
What is a lobectomy?
Surgical excision of a lobe of the lung.
44
How would you investigate a patient for a lobectomy?
Lung function tests - spirometry, lung volume measurements, diffusion capacity. Forced expiratory volume in one second (FEV1) and diffusing capacity of the lung for carbon monoxide (DLCO) are most useful. Imaging - CT chest within 6-12 weeks of surgery.
45
Given the findings of a thoracotomy scar what is your preferred diagnosis and differentials?
Lobectomy due to lung cancer, benign tumours, TB, lung abscess, emphysema, fungal infection. DDx pneumonectomy.
46
How would you manage a patient with a lobectomy?
MDT approach - smoking cessation services, prehabilitation and pulmonary rehabilitation.
47
What are the complications of a lobectomy?
Post op complications: infections, pneumothorax, haemothorax, bronchopleural fistula, empyema, pleural effusion.
48
What is the prognosis of a lobectomy?
Depends on reason for lobectomy.
49
Consultation - what are the symptoms of lung transplants?
Symptoms from underlying cause fo transplant - COPD (SOB), cystic fibrosis (productive cough), alpha-1 antitripsin deficiency, pulmonary hypertension (SOBOE) Symptoms from failing transplant - SOB, fever, cough.
50
What examination features would you expect to see in lung transplants?
Clamshell scar if double lung transplant. Thoracotomy if single lung transplant (right anterolateral for minimally invasive cardiac surgery).
51
Given the findings of clamshell incision what is your preferred diagnosis and differentials?
Double lung transplant due to COPD, cycstic fibrosis, bronchiectasis, pulmonary fibrosis.
52
What is a lung transplant?
Can be single or double lung transplant.
53
How would you investigate for lung transplants?
To investigate symptomatic patients to differentiate between rejection and other problems. Bloods - eosinophils, sputum cultures, CMV viral load. Pulmonary function tests - spirometry (obstruction and decreased FEV1 in rejection). Imaging - CXR (perihilar opacities or interstital oedema in rejection), high resolution CT (ground glass opacities, septal thickening, volume loss, pleural effusion in rejection). Pleural fluid analysis. Bronchoscopy.
54
How would you manage a patient with a lung transplant?
MDT approach with specialist nurse and transplant team. Immunosuppressive therapy usually a combination of: steroid, calcineurin inhibitor (e.g. tacrolimus or ciclosporin), nucleotide blocking agent (e.g. mycophenolate mofetil or azathioprine).
55
What are the complications of lung transplants?
Primary lung graft dysfunction. Acute and chronic lung transplant rejection. Bacterial, fungal, viral infection. Pneumothorax, chylothorax, venous thromboembolism. Airway and vascular anastomotic complications.
56
What is the prognosis of lung transplants?
Median survival for adult recipients is 7 years. (8 years for double, 5 years for single).
57
What examination features would you expect to see in pleural effusion?
Inspection - weight loss, nicotine staining, clubbing, rheumatoid changes in hands, dyspnoea, accessory muscle use, reduced expansion if large unilateral pleural effusion. Palpation - reduced chest expansion, trachea can be deviated away from effusion, decreased tactile vocal fremitus. Percussion - stony dull. Auscultation - diminished or absent breath sounds, lost vocal resonance.
58
Consultation - what are the symptoms of pleural effusions?
Shortness of breath especially on exertion, cough, pleuritic chest pain. Weight loss, smoking and haemoptysis (malignancy). Asbestos exposure etc.
59
How would you investigate for pleural effusions?
CXR - 200ml needed to be visible in PA view but can see 50ml causing costophrenic blunting on lateral view. US/CT/MRI for more imaging. Pleural fluid analysis - Light's criteria if protein 25-35g/L (ie borderline) looks at LDH and protein concentration in pleural fluid and serum. Exudative if one of the following: pleural fluid to serum protein ratio >0.5 or PF to serum LDH ratio >0.6, or PF LDH > 2/3 upper limit of normal for serum LDH. Exudate (protein >30g/L) - pneumonia, malignancy. Transudate (protein <30g/L) - heart failure, cirrhosis, hypoalbuminaemia.
60
Given the findings of reduced expansion on the left side and reduced breath sound with stony dull percussion on left side what is your preferred diagnosis and differentials?
Pleural effusion due to malignancy (lung or breast cancer), heart failure, cirrhosis, hypothyroidism, pneumonia, TB. DDx: haemothorax, empyema, chylothorax.
61
What are pleural effusions?
Increased fluid within the pleural space between the parietal and visceral pleura.
62
How would you manage a patient with pleural effusion?
Treat underlying cause. If transudate avoid aspiration. Tapping the fluid can help with symptoms and diagnosis, only take <1.5L at a time (fluid shift can cause pulmonary oedema). Chest drain for controlled drainage. Pleurectomy. Surgically implanted pleuroperitoneal shunts. Pleurodesis - sclerosant injected and causes adhesion of the visceral and parietal pleural to prevent reaccumulation of fluid.
63
What are the complications of pleural effusions?
Recurrence of pleural fluid. Respiratory distress.
64
What is the prognosis of pleural effusions?
Depends on cause. If malignant cause survival is only 3-12 months depending on underlying cancer.
65
Consultation - what are the symptoms of pneumonectomies?
Pre-pneumonectomy - symptoms based on cause of need for op - chronic cough, haemoptysis, shortness of breath, weight loss. Post-pneumonectomy - symptoms of complications e.g. infection.
66
What examination features would you expect to see in a pneumonectomy?
Thoracotomy scar. Trachea deviated towards scar. Breath sounds absent and vocal fremitus/resonance reduced over affected side. Can have bronchial breathing apically.
67
Given the findings of thoroactomy scar with trachea deviated towards scar and no breath sounds over that side what is your preferred diagnosis and differentials?
Pneumonectomy due to malignancy, benign tumours, pulmonary bullae e.g. from smoking or alpha-1 antitrypsin, bronchiectasis, infectious lung disease, COPD, trauma. DDx - lobectomy.
68
What is a pneumonectomy?
Removal of the entirety of one lung.
69
How would you investigate for pneumonectomies?
Pre pneumonectomy: pulonary function test (namely FEV1 and DLCO), cardiac risk assessment, imaging - CT within 12 weeks of surgery.
70
How would you manage a patient with a pneumonectomy?
MDT approach - smoking cessation services, prehabilitation and pulmonary rehabilitation.
71
What are the complications of pneumonectomies?
Pulmonary - oedema. Pleural space - empyema, bronchopleural or oesophagopleural fistula, chylothorax, contralateral pneumothorax, haemothorax. Cardiovascular - arrythmias, MI, embolism.
72
What is the prognosis of pneumonectomies?
Depends on reason for pneumonectomy, very variable. 30-day post op mortality can be up to 25%. 10 year survival can by 60-80% if non-small cell lung cancer.
73
What examination features would you expect to see in rheumatoid lung?
Signs of systemic disease. ILD - fine end-inspiratory bilateral crepitations. Bronchiectasis findings - shifting crackles, wet cough.
74
Consultation - what are the symptoms of rheumatoid lung?
Dyspnoea, cough wheeze. Can be asymptomatic. Respiratory symptoms can precede articular symptoms in 10-20%.
75
What is rheumatoid lung?
Extra-articular manifestation of rheumatoid arthritis, variable presentation.
76
Given the findings of rheumatoid features and lung symptoms what is your preferred diagnosis and differentials?
Rheumatoid lung - rheumatoid nodules, ILD, bronchiolitis, bronchiectasis, pleural effusion. DDx - infection, lung cancer
77
How would you investigate for rheumatoid lung?
Bloods - RhF, anti-CCP. Respiratory function tests - spirometry. CXR. Pleural fluid aspiration. High resolution CT. Lung biopsy.
78
How would you manage a patient with rheumatoid lung?
MDT approach - smoking cessation, pulmonary rehabilitation, review for LTOT, pulmonary hypertension clinic. Treat with immunosuppressive agents. DMARDS. Pirfenidone can reduce disease progression.
79
What are the complications of rheumatoid lung?
Respiratory failure. Death.
80
What is the prognosis of rheumatoid lung?
3-7 years if ILD. Worse if pulmonary hypertension alongside ILD.

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