1
Q
Approach to respiratory examination?
A
Inspection
Portable oxygen, sputum pot
Ask to breathe in - any obvious asymmetry in chest expansion
Cough - productive or non-productive
Hands
RA - symmetrical deforming polyarthropathy
Systemic sclerosis - sclerodactyly, thickened skin
DM - Gottron’s papules
Pancoast tumour - wasting in small muscles
Clubbing
CO2 retention - asterixis, erythema
Pulse
Face Horner's - meiosis, ptosis, anhidrosis Anaemia Cyanosis SLE - malar flush Systemic sclerosis - microstomia DM - heliotrope rash
Neck
Pulmonary HTN - raised JVP, large c-v waves
Tracheal deviation
Hyperinflation - reduced cricosternal distance
Cervical LN
Chest Scars - clamshell (transplant), thoracotomy (pneumonectomy/lobectomy), chest drain or pleural biopsy RV heave, palpable P2 Chest expansion Percussion TVF Auscultation + loud P2 Vocal resonance
At the end
Sacral or peripheral oedema
End exam by asking history, checking O2, possibly bedside spirometry
2
Q
Respiratory causes of clubbing?
A
- Abscess or empyema
- Asbestosis
- Bronchiectasis
- Cystic fibrosis
- Interstitial pulmonary fibrosis
- Tumours (bronchogenic carcinoma, mesothelioma)
- Extra question: causes of clubbing and crackles?
- Asbestosis
- Bronchiectasis
- Bronchogenic carcinoma
- Interstitial pulmonary fibrosis
3
Q
What is cor pulmonale?
A
- Right heart failure caused pulmonary hypertension as a result of disease affecting the lung and vasculature
- Permanent remodelling of pulmonary vasculature leading to pulmonary hypertension, which then alters the RV structure and function
4
Q
Cor pulmonale - symptoms?
A
Dyspnoea Fatigue and lethargy Exertional chest pain Orthopnoea Hoarseness of voice (compression of left recurrent laryngeal nerve by dilated main pulmonary artery)
5
Q
Cor pulmonale - clinical signs?
A
- Ruddy facial appearance (polycythaemia)
- Central cyanosis
- Bounding pulse, flapping tremor (C02 retention)
- Raised JVP - prominent a wave (right atrial hypertrophy), large v wave (TR)
- Left parasternal heave (RV hypertrophy) - may not be palpable in hyper inflated lungs
- Palpable P2
- Wide splitting of S2 (in inspiration), loud P2
- PSM loudest at lower LSE in inspiration (TR)
- EDM loudest in pulmonary area (Graham-Steele PR)
- 4th heart sound (RV hypertrophy)
- Hepatomegaly
- Sacral and ankle oedema
6
Q
Cor pulmonale - investigations?
A
- Pulse oximetry
- ABG: type 1/2 resp failure + assess for requirement for LTOT
- CXR: cardiomegaly, prominent pulmonary arteries
- ECG: right axis deviation, prominent P waves (p pulmonale), RBBB
- ECHO: RV hypertrophy, TR, paradoxical inter ventricular septum movement
- Right heart catheterisation: gold standard to diagnose pulmonary HTN
7
Q
Cor pulmonale - management?
A
- Manage underlying conditions
- Consider LTOT
- Diuretics (judicious use as excessive diuresis can reduce filling pressure and RV output)
8
Q
Cor pulmonale - causes?
A
- COPD
- Interstitial lung disease
- OSA
- Hypoventilation disorders: OHS, neuromuscular disorders, kyphoscoliosis
9
Q
Indications for LTOT?
A
PaO2 < 55mmHg (<7.2kPa) or SO2 < 88%
PaO2 < 60mmHg (<8kPa) with cor pulmonale or erythrocytosis
10
Q
Definition of pulmonary hypertension?
A
Mean pulmonary artery pressure > 25mmHg
Left atrial pressure < 15mmHg
Caused by increase in pulmonary blood flow and increase in pulmonary vascular resistance
11
Q
Causes of pulmonary hypertension?
A
WHO has classified pulmonary hypertension as follows:
- Pulmonary arterial hypertension - idiopathic, familial, disease related to collagen vascular disease, HIV and drugs
- Pulmonary venous hypertension - due to left-sided disease
- Chronic lung disease or hypoxaemia - COPD, ILD, OSA
- Chronic thromboembolic disease - PE, sickle cell disease
- Miscellaneous disorders - sarcoidosis, Langerhan cell histiocytosis, myeloproliferative disease, thyroid disease
12
Q
Bronchiectasis - features and clinical signs?
A
Features:
- Dyspnoea
- Cough with daily copious purulent sputum
- Haemoptysis
- Pleuritic chest pain
- Weight loss, failure to thrive
- Recurrent infections
- Hx of sinusitis, childhood infection, TB, sub fertility
Clinical signs:
- Copious purulent sputum in sputum pot at bedside
- Cachexia
- Tachypnoea
- Central cyanosis
- Finger clubbing
- Hyperexpanded chest
- Coarse, late, inspiratory crepitations
- Wheeze
13
Q
Bronchiectasis - investigations?
A
Labs
- Sputum C&S, AFB, MTB C&S, fungal, cytology
- Bloods: FBC (anaemia of chronic disease, polycythaemia less commonly, neutrophilia)
Lung function test - obstructive pattern (FEV1 low, FVC low or normal, FEV1/FVC < 0.7)
Imaging
- CXR: hyper inflated, finger-in-glove appearance (mucus plugging), tram lines and ring shadows (dilated and thickened airways), honeycomb patterns in severe cases
- HRCT (definitive test): tram tracking and ring shadows (thickened dilated bronchi), signet ring sign (thickened dilated bronchi > 1.5x larger than adjacent pulmonary vessels), pus/fluid levels in dilated bronchi, mucus plugging or bronchoceles
Bronchoscopy - rarely needed, required to obtain microbiological samples or exclude other conditions
Specific tests
- Serum Ig (hypogammaglobulinaemia)
- Alpha 1 antitrypsin level (deficiency)
- Aspergillum precipitins and IgE (ABPA)
- Autoantibodies (if CTD suspected)
- Sweat test (Cl > 60mmol/L) and genotyping (CF)
- Nasal brushings and electron microscopy to visualise ciliary structure (Kartagener’s) -> refer sp centre!
- AFB, MTB C&S, Tuberculin test (TB)
14
Q
Bronchiectasis - treatment?
A
- General measures
- Education of patient and family
- Optimise nutrition e.g. calorie supplementation
- Smoking cessation
- Vaccination: pneumococcal and influenzae
- Physiotherapy: chest percussions, postural drainage, breathing exercises, nebulised saline - Medical
- Antibiotics for infective exacerbation, which often will need pseudomonas coverage
- Bronchodilators if evidence of reversibility
- Corticosteroids either inhaled or oral, during exacerbation
- Mucolytics
- Nebulised hypertonic saline for mucus plugging - Surgical - lobectomy or pneumonectomy (specific indications based on localised disease and good lung function), transplantation in CF
- Treatment of underlying disease
15
Q
Bronchiectasis - causes?
A
Abrnomal, permanent dilatation of bronchi due to combination of infections, impaired drainage, obstruction and defective immune host response.
- Congenital
- CF: caucasian, short stature, clubbing, diabetes, sinusitis, infertility
- Young’s syndrome: similar clinical features to CF but no CF mutation, abnormal sweat or pancreatic insufficiency
- Kartagener’s syndrome: sinusitis, situs inversus, dextrocardia, subfertility, otitis media
- Yellow nail syndrome: yellow nail, pleural effusion, lymphoedema - Bronchial obstruction
- Foreign body
- Carcinoma
- Sarcoidosis/TB - Infection
- Whooping cough, TB, measles - Overactive immune response
- ABPA
- CTD: RA
- IBD - Underactive immune response - hypogammaglobulinaemia, HIV, leukaemia
- Chemical injury - recurrent aspiration in stroke, bulbar neurological disease, chronic alcoholism
- Other resp disease - COPD, fibrosis
16
Q
Bronchiectasis - how to determine severity?
A
- Symptoms: Medical Research Council (MRC) Dyspnoea scale
- Lung function assessment: FVC/FEV1
- Imaging: number of bronchopulmonary segments involved
17
Q
Bronchiectasis - complications and major pathogens?
A
Complications
- Pulmonary: recurrent infections, haemoptysis, empyema/abscess, cor pulmonale
- Extrapulmonary: anaemia, metastatic infections e.g. cerebral abscess, secondary amyloidosis
Major pathogens
- Pseudomonas aeruginosa
- Haemophilus influenza
- Streptococcus (less commonly)
- Burkholderia cepacia complex (in CF associated with accelerated decline in pulmonary function and decreased survival)
18
Q
COPD - definition and types?
A
- Progressive airflow obstruction with limited reversibility
- Characterised by abnormal inflammatory lung response to cigarette smoke or other inhaled noxious particle
Types:
- Chronic bronchitis - clinical diagnosis of chronic productive cough for > 3 months in 2 consecutive years
- Emphysema - histological and radiological diagnosis of abnormal and permanent enlargement of airways distal to terminal bronchioles, and destruction of alveolar wall
19
Q
COPD - clinical features?
A
Symptoms
- Chronic productive cough
- Exertional dyspnoea
- Recurrent infections
- Wheeze
Signs
- Bedside: inhalers, sputum pot, oxygen
- Inspection: cachexia, tachypnoea, pursed-lip breathing, barrel chest, use of accessory muscles, peripheral/central cyanosis, tar-stained fingers
- Asterixis and bounding pulse (CO2 retention)
- Hyperinflated chest
- Hyper-resonance to percussion + reduced hepatic and cardiac dullness
- Reduced breath sounds esp over bull
- Expiratory wheeze, prolonged expiratory phase
- Inspiratory coarse crackles
- Possible signs of prolonged steroid use: Cushingoid features, bruising, thin skin
- Signs of cor pulmonale: right parasternal heave, palpable and loud P2, raised JVP with prominent v waves, PSM of TR, peripheral oedema
20
Q
COPD - investigations?
A
Labs
- Sputum culture
- Bloods: FBC (anaemia, polycthaemia, neutrophilia), raised CRP, low albumin (chronicity of disease)
- ABG: resp failure hypoxaemia and hypercapnia with chronic disease
- Alpha 1 antitrypsin: indicated in early-onset disease with minimal smoking history, or family history
Lung function test
- Airflow obstruction FEV1/FVC < 0.7
- Severity assessment based on FEV1
- Minimal reversibility with bronchodilator
- Increased TLC, residual volume and functional residual capacity
Imaging
- CXR
- Hyperinflated lungs with flattened diaphragm
- Bullae
- Cardiac enlargement: cor pulmonale
- Prominent pulmonary vasculature: pulmonary hypertension - HRCT
- Grade and classify emphysema: centrilobular in upper lobes, pan lobular in lower lobes, paraseptal anywhere/adjacent to septa and pleura - ECHO
- Evaluate pulmonary hypertension/cor pulmonale
21
Q
COPD - role of spirometry?
A
- Diagnosis: FEV1/FVC < 0.7
- Assessment of severity of airflow obstruction: GOLD grade 1-4
- Follow-up assessment:
a) Therapeutic decision
- Surgical interventions e.g lung volume reduction surgery, bullectomy, transplantation
- Discrepancy between initial FEV1 severity and symptoms
b) Identification of rapid decline
22
Q
COPD - treatment?
A
Aim: reduce symptoms, reduce frequency/severity of exacerbations, improve QoL and exercise capacity
Non-pharmacological
- Patient education
- Smoking cessation - slow rate of lung function decline
- Optimize nutrition
- Vaccination with influenza and pneumococcal vaccines
- Physiotherapy and behavioural therapy
Medical
- Short-acting bronchodilators
- SABA (salbutamol, terbutaline): improve symptoms and FEV1
- SAMA (ipratropium): improve symptoms - Long-acting bronchodilators
- Persistent symptoms or > 2 exacerbations per year
- Improve symptoms, lung function, QoL and reduce exacerbations
- LABA (formoterol, salmeterol, indacaterol, vilanterol)
- LAMA (tiotropium, glycopyrronium bromide, umeclidinium) - ICS -> in moderate to severe COPD
- LABA/ICS more effective than individual components: improve lung function, QoL and reduce exacerbations
- LABA/LAMA/ICS is better than LABA/ICS, LABA/LAMA or LAMA
- Regular ICS increases risk of pneumonia esp in severe COPD
- Greater benefit in preventing exacerbations with ICS treatment in serum Eos > 300cells/uL - Methylxanthines
- Theophylline, aminophylline -> unclear mechanism of action, suggested to relax airway smooth muscles
- Small bronchodilator effect in stable COPD
- Potential toxicity, not recommended as initial treatment - Long-term oxygen therapy
- PaO2 < 55mmHg (< 7.2kPa) or < 60mmHg (< 8kPa) in cor pulmonale or secondary polycythaemia
Surgical
- Lung volume reduction surgery
- Symptomatic despite maximal medical therapy, FEV1 > 20%, predominantly upper lobe emphysema
- Remove area of poorly functioning lung, so that physiologically useful lungs can expand
- Improve exercise capacity, QoL and mortality - Bullectomy
- Symptomatic despite maximal medical therapy, FEV1 < 50% and bullae > 1/3 hemithorax
- Reduce airway resistance and improve elastic recoil
- Improve symptoms and lung function - Lung transplant
- BODE > 5, FEV1 < 25%, accelerated decline in FEV1, resting hypoxaemia and hypercapnia, secondary pulmonary hypertension
- Improve functional capacity
23
Q
COPD - how to define severity?
A
- Medical Research Council (MRC) Dyspnoea scale, grade 0-4
- Grade 0: breathless with strenuous exercise
- Grade 1: breathless hurrying on the level or walking uphill
- Grade 2: breathless walking at my pace on the level, slower than people my age
- Grade 3: breathless walking 100m on the level
- Grade 4: breathless at home or with dressing - Lung function assessment for airflow obstruction using GOLD staging:
- FEV1 > 80% predicted: mild
- FEV1 50-80% predicted: moderate
- FEV1 30-50% predicted: severe
- FEV1 < 30% or < 50% with chronic resp failure: very severe - BODE index (assess mortality and hospitalisation risk)
- Pulmonary and extra pulmonary manifestations
- FEV1, 6-min walking distance, MRC scale, BMI
24
Q
COPD - difference between GOLD 1-4 grading and GOLD A-D groups?
A
GOLD 1-4 grading is to determine severity of airflow obstruction (FEV1) -> for prognosis
GOLD A-D groups is for information regarding:
- Symptoms burden
- Risk of exacerbation
- Guiding therapy for individualised patient care
-> GOLD grade (based on FEV1), group (based on symptoms and exacerbation)
25
COPD - how to differentiate with asthma?
1. Clinical features:
- COPD: associated with smoking, persistent and progressive cough and breathlessness
- Asthma: variable symptoms, nocturnal awakening with breathlessness and wheeze, hx of atopy
2. Lung function
- COPD: minimal reversibility with bronchodilators
- Asthma: FEV1 improvement > 200-400ml with bronchodilators, serial peak flow shows diurnal or day-to-day variability
26
Treatments available to stop smoking?
1. Nicotine replacement therapy - gum, patch, inhalers, sprays
2. Bupropion - antidepressant which enhances CNS noradrenergic and dopaminergic activity
3. Varenicline - nicotinic Ach receptor agonist
Some evidence of increased efficacy with combination therapy
27
Pleural effusion - clinical findings and important negatives?
```
Important negative:
Clubbing (malignancy)
Cachexia and nutritional status (malignancy, hypoalbuminaemia)
Rheumatoid hands/nodules
Butterfly rash
Lymphoedema (malignancy, sarcoidosis)
Raised JVP (RHF, pulmonary HTN)
```
Findings:
- Scars from chest tube
- Tracheal deviation away from effusion if large > 1000ml (if central in the context of large effusion, then suggests collapse)
- Reduced chest expansion
- Reduced vocal fremitus
- Stony dullness
- Diminished breath sounds with bronchial breathing at area above effusion
28
Pleural effusion - investigations?
Labs
- Pleural fluid analysis: LDH, protein, albumin, glucose, pH, AFB stain, culture, cytology
- Serum LFT, LDH, FBC, RP, ESR, CRP, blood culture
- Specific tests: TFT, ANA/RF (if CTD suspected), amylase (if pancreatitis suspected)
- Sputum culture, AFB
CXR
- Blunted CPA, meniscus sign
USG thorax
- Differentiate pleural effusion from pleural thickening
- Guide thoracocentesis
- Identify loculated effusions
If suspect malignancy/infection/TB:
- CT thorax
- Bronchosopy/CT-guided biopsy
- Pleural biopsy
29
Pleural effusion - Light's criteria, and other pleural fluid analysis?
Light's criteria for exudates (1 of 3 criteria):
- Pleural/serum albumin ratio > 0.5
- Pleural/serum LDH ratio > 0.6
- Pleural LDH > 2/3 upper normal limit of serum LDH
Pleural fluid analysis:
- Protein: > 30g/dL exudates
- pH: < 7.2 indicates empyema or complicated parapneumonic effusion
- Glucose: < 2mmol/L -> MEAT: malignancy, empyema, arthritis (RA), TB
- Cytology: malignancy
- Gram stain/culture/AFB: infection/TB
- ADA: raised indicates excessive purine metabolism or T-lymphocyte process (causes same as glucose)
- Cholesterol: TG > 1.3mmol/L indicates chylothorax
- Amylase: pancreatitis, oesophageal rupture, malignancy, pneumonia
30
Pleural effusion - weaknesses of Light's criteria in differentiating transudates from exudates?
- 25% transudates are mistakenly identified as exudates
- If transudates are suspected, calculate serum-pleural albumin gradient
- Albumin gradient > 1.2g/dL indicates transudates
31
Pleural effusion - management?
Treat underlying cause
Common principles:
- Oxygen therapy, IV hydration, chest physio
- Diagnostic and therapeutic thoracocentesis
- Chest tube insertion: empyema, malignant effusion, recurrent effusion
- Drainage done slowly to avoid intravascular collapse, re-expansion pulmonary oedema
- Abx for infection
- Diuresis for failure
- Pleurodesis for recurrent effusion: medically with talc or surgically via VATS
Mechanism of pleurodesis
Agent instilled into pleural cavity to induce inflammatory response
Inflammatory response resolves by fibrosing visceral and parietal pleura together
32
Pleural effusion - types and causes?
Types:
1. Exudate
2. Transudate
3. Chylothorax
4. Haemothorax
5. Empyema
6. Drug-induced
Exudate and transudate are differentiated by Light's criteria
Causes of exudates (PINTS):
- PE
- Infection: TB, pneumonia
- Neoplasm: bronchogenic carcinoma, mesothelioma, secondary breast/ovary/pancreas
- Trauma
- Sarcoidosis/SLE/Subdiaphragmatic (hepatic abscess, panceatitis)
Causes of transudates (CHAM):
- CCF
- Hypothyroidism/hypoalbuminaemia
- Any failure (renal, hepatic, cardio)
- Meig's syndrome (benign ovarian fibroma with often right pleural effusion)
Causes of chylothorax:
- Lymphatic obstruction: lymphoma
- Lymphatic damage: thoracic surgery
- Nephrotic syndrome
- Cirrhosis
33
Pleural effusion - causes of drug-induced effusions?
- Drug-induced lupus: procainamide, quinidine, hydralazine
- MTX
- Nitrofurantoin
- Bromocriptine
34
Pleural effusion - is pleural fluid AFB reliable for diagnosis of pleural TB?
- Effusion in TB is often the hypersensitivity reaction to mycobacterium rather than direct microbial invasion hence < 10% AFB positive
- Diagnostic yield increased with TB culture and pleural biopsy
- ADA can send but not specific
- IFN gamma can send but not widely available
35
Pleural effusion - outline 5 major processes
1. Increased hydrostatic pressure and reduced intravascular oncotic pressure (transudate)
2. Increased capillary permeability (exudate)
3. Bleeding into pleural space (haemothorax)
4. Impaired lymphatic drainage (chylothorax)
5. Infection within pleural space (empyema)
36
Complications of pleural drainage?
- Pneumothorax
- Haemothorax
- Intravascular collapse
- Re-expansion pulmonary oedema
37
Pulmonary fibrosis - clinical findings?
Clinical findings:
- Central cyanosis
- Trachea central if bilateral, deviated to side of lesion if unilateral
- Usually equal chest expansion
- Percussion normal or dull
- TVF/vocal resonance normal or increased
- Fixed end inspiratory fine crepitations (do not alter with coughing)
Important negatives:
- Resp failure - oxygen therapy
- Peripheral signs of CTD, RA
- Irregular pulse: Amiodarone therapy for AF
- Pulmonary HTN
- Signs of chronic steroid use
38
Pulmonary fibrosis - investigations?
1. Labs
- ABG
- CTD screen: ANA (SLE), RF/anti-CCP (RA), anti-Ro/La (Sjogren), anti centromere (limited systemic sclerosis), anti Scl 70 (diffuse systemic sclerosis), anti-Jo1 (DM)
- CK (DM, PM)
- Avium antigen precipitins (EAA)
- Serum ACE (sarcoidosis)
2. Pulmonary function test
- Restrictive pattern: FEV1 and FVC reduced, preserved ratio > 0.7
- Reduced transfer factor
3. CXR
- Some normal
- Others reticulonodular pattern
4. HRCT Thorax
- Diagnostic in most cases
- Reticular pattern
- Honeycombing in advanced disease
- GGO suggesting inflammation and potential response to steroids
5. Bronchoscopy + BAL + transbronchial biopy (or even surgical lung biopsy)
- If aetiology or diagnosis is uncertain
6. ECHO
- Pulmonary HTN or RV failure
39
Pulmonary fibrosis - treatment?
1. MDT approach - specialist respiratory nurse, physiotherapy, rehab physician, medical physician, surgeon (possibly biopsy or transplant)
2. Supportive - supplemental oxygen
3. Depending on cause:
- IPF: UIP (pirfenidone/nintedanib in FVC 50-80% predicted could slow down progression), NSIP (steroids or immunosuppressants)
- EAA: steroids and removal of precipitants
- CTD: treatment of underlying cause, usually includes steroids or immunsuppressants
4. Lung transplant
40
Pulmonary fibrosis - causes?
```
Upper zone fibrosis (CHARTS):
Coal worker's pneumoconioses
Histoplasmosis
Histiocytosis
ABPA
Allergic extrinsic alveolitis
Ankylosing spondylitis
Radiation therapy
TB
Sarcoidosis/Silicosis
```
```
Lower zone fibrosis (RATIO):
RA
Asbestosis
Tissue (CTD) - SLE, scleroderma, DM, PM, MCTD
Idiopathic pulmonary fibrosis
Others - drugs, bronchiectasis
```
Asymmetrical fibrosis:
Treated TB
Malignancy
41
Pulmonary fibrosis - describe the different groups of causes?
1. Idiopathic:
a) Sarcoidosis
b) Idiopathic interstitial pneumonias
- Usual interstitial pneumonia (UIP): describes IPF, poor prognosis, not responsive to steroids/immunosuppressants
- Non-specific interstitial pneumonia (NSIP): better prognosis, potential response to steroids/immunosuppressants
- Desquamative interstitial pneumonia
- Cryptogenic organizing pneumonia/bronchiolitis obliterans organizing pneumonia (BOOP): clinically resembles pneumonia, but cultures -ve and no response to abx
- Respiratory bronchiolitis-ILD
- Acute interstitial pneumonia
2. Occupational exposure (metal/mineral/dust):
- Asbestosis, silicosis, berylliosis, coal
3. Allergen exposure:
- Bird fancier's lung (pigeons)
- Farmer's lung (mouldy hay)
- Malt worker's lung (mouldy barley)
- Mushroom worker's lung (mushroom spores)
4. Rheumatological disease
- RA, SLE, systemic sclerosis, Sjogren, PM, DM, MCTD, AS
5. Drugs (BBC MANS Gold PR)
- Bleomycin
- Busulphan
- Cyclophosphamide
- MTX
- Amiodarone
- Nitrofurantoin
- Sulphasalazine
- Gold
- Paraquat
- Radiation
6. TB
42
Pulmonary fibrosis - what causes high lymphocyte counts on BAL?
- Sarcoidosis
- Organizing pneumonia
- EAA
43
Pulmonary fibrosis - poor prognostic factors in IPF?
- Older age
- Low exercise tolerance + exertional desaturation
- Declining pulmonary function
- Pulmonary HTN
- Extensive radiographic involvement
- UIP subtype
44
Rheumatoid lung - respiratory manifestations and clinical signs?
Resp manifestations:
- Bronchiectasis (directly due to RA, or post-infective complications from immunosuppression)
- Bronchiolitis obliterans (rare - obstructive, hyperinflation, exp wheeze, inspiratory squawks)
- Pulmonary nodules (predilection to upper lobes, often asymptomatic, but can become infection, cavitation, bronchopulmonary fistula)
- Pulmonary fibrosis
- Pleural effusion
- Pulmonary HTN (due to fibrosis or bronchiectasis)
- Bronchogenic carcinoma (rare)
- Caplan's syndrome: coal worker's pneumoconioses + RA
Clinical signs:
- Symmetrical deforming polyarthropathy sparing DIPJ
- Ulnar deviation
- Rheumatoid nodule (REMEMBER ELBOWS!)
- Signs of steroid use
45
Rheumatoid lung - treatment?
- Most CTD-ILD has NSIP histological pattern -> responds to steroids or immunosuppressants
- EXCEPT RA, in which UIP more common -> not steroid-responsive, more difficult to treat, poorer prognosis
- No licensed treatment for RA-related UIP type ILD
- Ultimately is to treat underlying RA, or eliminate offending drugs
46
Lung cancer - symptoms?
- Productive cough
- Haemoptysis
- Dyspnoea
- Chest pain
- Weight loss
- Hoarseness of voice
- Symptoms of metastasis: bony pain, focal neurology, jaundice
- Symptoms of paraneoplasm: confusion, bony pain, mood changes, constipation, proximal weakness that improves with exercise, double vision
47
Lung cancer - clinical signs?
Clinical signs:
- Cachexia
- Clubbing
- Tar staining
- Lymphadenopathy
- Trachea deviation away from effusion, towards collapse or fibrosis
- Reduced chest expansion
- Reduced vocal fremitus and resonance
- Stony dullness over effusion, dullness over collapse
- Diminished breath sounds
Previous scars:
- Mediastinoscopy: small horizontal scar over suprasternal notch
- Chest drain or VATS
- Pleural biopsy
- Lobectomy or pneumonectomy
- Radiation tattoos or radiation burns
Complications of direct tumour invasion:
- Hoarseness of voice: left recurrent laryngeal nerve palsy
- Ipsilateral Horner's syndrome: Pancoast tumour invasion to paravertebral sympathetic chain
- Ipsilateral small muscle hand wasting, weakness and paraesthesia C8-T1: Pancoast tumour invasion to brachial plexus
- SVC obstruction
Complications of metastasis:
- Bony deformity or tenderness
- Hepatomegaly or jaundice
- Focal neurology: brain mets or spinal cord compression
Signs of paraneoplastic syndromes:
- Polymyositis, dermatomyositis
- Erythema gyratum repens
- Acanthosis nigrans
- Gynaecomastia
- Hypertrophic pulmonary osteoarthropathy
- Proximal weakness, autonomic dysfunction, cranial nerve involvement
- Cerebellar syndrome
48
Lung cancer - investigations?
Main objective is to obtain histological diagnosis and stage the disease.
Bloods
- FBC: anaemia
- LFT: liver mets, raised ALP bone mets
- RP: hyponatraemia SiADH, hypokalaemia ectopic ACTH, hypercalcaemia bone mets or PTHrP
Sputum
- Cytology: good yield for endobronchial tumours, poor yield for peripheral tumours
Pleural analysis
- pH < 7.2, glucose < 2, exudative, haemorrhagic fluid, cytology
Pulmonary function test
- Assess suitability for lung resection: FEV1 > 2L can tolerate pneumonectomy, FEV1 > 1.5L can tolerate lobectomy
- Predicted post-operative pulmonary function: FEV1, transfer factor
- Cardiopulmonary exercise testing: maximal oxygen consumption via VO2 max, > 15ml/kg/min suitable for surgery
Imaging
- CXR: multiple findings - spiculated lesions, mass, pleural effusion, collapse consolidation, mediastinal enlargement
- CT thorax/abdomen with contrast: evaluate size of tumour and staging, lymph node involvement and mets
- MRI: more effective to evaluate spine and brain mets
- PET scan: superior than CT to assess mediastinal nodal mets
- Technetium-labelled bone scan: if bone mets suspected
Histological sampling
- CT-guided biopsy: peripherally located tumours
- USG-guided biopsy: peripheral lymph nodes or liver mets
- Flexible bronchoscopy:
a) Assess position within bronchial tree
b) BAL cytology
c) Endobronchial biopsy or brushings
d) Endobronchial USG (EBUS) for mediastinal lymph node sampling
e) EBUS + with transbronchial needle aspiration (TBNA) superior than blind TBNA
- Mediastinoscopy: relatively uncommon now, scar above sternal notch in midline
- VATS or pleural biopsy
49
Lung cancer - treatment?
MDT management including lung cancer nurse specialists to provide support and coordinate care.
Prognostic factors guiding treatment: disease staging, WHO performance status.
NSCLC
- Stage 1,2 sometimes 3A on individual basis: surgical resection if suitable (25%), offers best long-term survival
- Radiotherapy stage 1,2,3 if not suitable for surgery + good performance status
- Chemotherapy stage 3,4 with good performance status: platinum-based + 3rd generation
- Stage 4 palliative therapy: analgesics, anti-emetics, steroid may improve appetite, chemo prolong survival without impairment to QoL, radiotherapy for bone pain/haemoptysis/bronchial obstruction/SVC obstruction/Pancoast's tumour
SCLC
- Rapidly proliferating and often have disseminated disease at presentation
- Combination chemo and radiotherapy
- Prophylactic cranial irradiation: reduce incidence of brain mets, prolong survival
- Palliative therapy
50
Lung cancer - risk factors?
- Smoking
- Interstitial lung disease
- Radiation therapy
- Environmental and occupational exposure: asbestos, radon, arsenic, chromium (adenocarcinoma)
- Genetic factors: increased risk in patients with FHx
51
Lung cancer - histological classification?
Staging classification of NSCLC?
Staging classification of SCLC?
Histological classification:
- NSLC 80%: squamous cell (central), adenocarcinoma (peripheral), alveolar cell, large cell
- SCLC 20%: rapidly proliferating, early dissemination
NSCLC
- TNM classification: based on tumour size, nodal involvement and distant mets
- T1 < 3cm, T2 > 3cm or > 2cm from carina, T3 Pancoast tumour etc, T4 involvement to carina/other chest organs/malignant pleural or pericardial effusion
- N3 scalene/supraclavicular node involvement
- M1 distant mets
- Staging: 1A, 1B, 2A, 2B (T3 above), 3A, 3B (N3 above), 4 (M1)
SCLC
- Limited disease: confined to ipsilateral hemithorax, survival < 2 years
- Extensive disease: mets to outside ipsilateral hemithorax, survival < 18 months
52
Lung cancer - prognostic factors to help guide treatment?
- Weight loss
- WHO performance status
0: asymptomatic
1: symptomatic, ambulatory, can do light work
2: in bed < 50% of the day
3: in bed > 50% of the day, unable to care for self
4: bed-ridden
53
Lung cancer - common sites of metastases?
- Other lung
- Liver
- Bone
- Brain
- Adrenal glands
54
Lung cancer - paraneoplastic manifestations?
Often associated with SCLC, but some with NSCLC (*)
MSK
- Hypertrophic pulmonary osteoarthropathy: clubbing and pain at wrists (*)
- Polymyositis
- Dermatomyositis
CNS
- Lambert-Eaton myasthenic syndrome: slowly progressive proximal myopathy, autonomic dysfunction, cranial nerve involvement; weakness improves with exercise, anti VGCC positive
- Cerebellar syndromes
- Peripheral neuropathy
Endocrine
- PTHrP: hypercalcaemia (*)
- SiADH: hyponatraemia, low serum osm, high urine osm, high urine Na
- Ectopic ACTH: hypokalaemia, Cushing's syndrome, pigmentation
- BHCG: gynaecomastia
Dermatology
- Acanthosis nigricans
- Erythema gyratum repens
55
SVC obstruction - symptoms and clinical signs?
Symptoms:
- Cough
- Dyspnoea
- Dysphagia
- Hoarse voice
- Headache esp on leaning forward or lying down
- Pre-syncope/syncope
Clinical signs:
- Cachexia
- Facial and upper limb oedema
- Plethora, conjunctival suffusion, venous angioma at undersurface of tongue
- Cyanosis
- Malignancy: clubbing, tar-staining, small muscle hand wasting, Horner's syndrome, radiation burns or tattoos
- Elevated fixed JVP
- Distended superficial veins over neck, chest, upper limbs
- Pemberton sign: worsening signs upon raising both arms above head simultaneously
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SVC obstruction - investigations?
- CXR: mediastinal widening, hilar lesion
- CT contrast: level and extent of blockage, collateral vessels, possibly underlying cause
- CT venography
57
SVC obstruction - treatment?
Treat underlying cause:
- Chemo and/or radiotherapy (SCLC, NSCLC, lymphoma)
- Anticoagulation or thrombolysis (thrombosis)
Relieve symptoms:
- Elevate head
- Steroids (esp resp compromise or cerebral oedema)
- Radiotherapy
- Percutaneous endovascular stent: whilst histological diagnosis is pursued
58
SVC obstruction - causes?
- Lung Ca: SCLC > NSCLC
- Lymphoma esp NHL
- Mediastinal masses e.g. thymoma, goitre
- Post-radiation fibrosis
- Thoracic aortic aneurysm
- Thrombosis esp central venous catheter insertion
59
Lobectomy and pneumonectomy - clinical signs?
- Lateral thoracotomy
- Tracheal deviation towards side of lesion in pneumonectomy and upper lobe lobectomy
- Reduced chest expansion
- Reduced breath sounds
- Signs of bronchiectasis: clubbing, coarse crepitations, chesty cough
- Signs of lung Ca: clubbing, nicotine tar staining, hand wasting, Horner's syndrome, lymph nodes, radiation burns
- Signs of old TB: supraclavicular scar indicating phrenic nerve crush
60
Lobectomy and pneumonectomy - chest radiographic features?
- Surgical clips and rib resection
- Tracheal deviation
- White out in pneumonectomy
- Volume loss in lobectomy
- Compensatory hyperinflation of opposite lung in pneumonectomy and ipsilateral lobes in lobectomy
61
Lobectomy and pneumonectomy - indications?
- Lung malignancy
- Localised bronchiectasis and uncontrolled symptoms, such as recurrent haemoptysis
- Traumatic lung injury
- Large emphysematous bullae
- Fungal infections
- Congenital CF
- Old TB
62
Lobectomy and pneumonectomy - subtypes of pneumonectomy?
1. Simple - removal of affected lung
2. Extrapleural - removal of affected lung, part of diaphragm, parietal pleura and pericardium on ipsilateral side -> usually in malignant mesothelioma, produces best survival rate
63
Lobectomy and pneumonectomy - operative mortality?
| Any differences between right and left side?
Lobectomy 2-4%
Pneumonectomy 6%
Right side pneumonectomy higher mortality (10%) compared to left side (1-3.5%)
Higher incidence of post-pneumonectomy oedema, empyema, bronchopleural fistula
64
Lobectomy and pneumonectomy - what is post-pneumonectomy syndrome?
- Occurs almost exclusively in right-sided pneumonectomy
- Compensatory hyperinflation and mediastinal shift post-pneumonectomy causes compression on distal trachea and bronchus
- Presents with cough, dyspnoea, inspiratory stridor, pneumonia
- Treatment with surgical repositioning of mediastinum and filling of post-pneumonectomy space with non-absorbable material
65
VATS - indications and benefits vs open thoracotomy?
Indications:
- Wedge resection or segmentectomy
- Lobectomy
- Decortication
- Bullectomy
- Treatment of recurrent pneumothoraces
Benefits:
- Shorter healing time
- Reduced pain
- Reduced wound complications
- Reduced hospital stay
66
Old TB - symptoms (active) and clinical signs?
Symptoms:
- Fever
- Night sweats
- Weight loss
- Chronic productive cough
- Haemoptysis
- Dyspnoea
- Pleuritic chest pain
Clinical signs of old TB:
- Clubbing
- Thoracotomy + supraclavicular scar of phrenic crush
- Tracheal deviation towards the side of lesion if upper lobe lobectomy
- Reduced chest expansion
- Dull percussion
- Crepitations - fine end-inspiratory over areas of fibrosis, coarse over areas of bronchiectasis
67
Old TB - investigations?
- Sputum AFB, MTB C&S
- Mantoux test
- IGRA (interferon gamma release assay): more sensitive and specific than Mantoux, less likely to cause false negative results e.g. in immunosuppression, or false positive results e.g. in response to previous BCG
- HIV
- CXR: hilar lymphadenopathy, pulmonary infiltrates and cavitation esp upper lobes, pleural effusion
- CT: more sensitive than CXR, look for consolidation, centrilobular nodules connected to multiple branching linear structures (tree in bud), GGO, miliary nodules
- Bronchoscopy
- Biopsy of extrapulmonary sites
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Old TB - treatment of active disease, and side effects?
- Notifiable disease
- Initiate contact tracing
- Screen for HIV, check renal and liver profiles, eye screening documenting baseline visual acuity and colour vision before starting treatment
- Discuss DOTS
- 4 abx therapy whilst awaiting sensitivity results: EHRZ for 2 months, once sensitivity available and is fully sensitive, then continue on with 2 abx therapy HR for 4 months
Side effects:
- RIF: hepatotoxicity, thrombocytopaenia, GI disturbance
- INH: hepatotoxicity, peripheral neuropathy, optic neuropathy
- ETH: optic neuropathy/neuritis
- PZA: hepatotoxicity, peripheral neuropathy, gout, GI disturbance
69
Old TB - treatment before era of effective antibiotics?
Surgical procedures to induce lobar collapse, to 'starve mycobacterium from oxygen'
- Plombage: inserting wax, plastic balls or gauze at pleural space to compress the lung
- Thoracoplasty: rib resection
- Phrenic nerve crush: paralyse nerve on affected side
70
Old TB - complications and extrapulmonary manifestations?
Complications:
- Apical fibrosis
- Bronchiectasis
- Aspergilloma in old TB cavity
- Pleural effusion or thickening
- Abscess or empyema
- Pneumothorax
Extrapulmonary manifestations:
- CVS: pericardial TB
- GI: lymph nodes, GI obstruction esp terminal ileal disease
- Renal: prostatitis, epididymitis
- Neuro: TB meningitis, tuberculoma
- Spine: thoracic kyphosis, Gibbus deformity
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Old TB - risk factors for active infection?
- Immunosuppressive states: HIV, AIDS, DM, renal disease, malignancy, on immunosuppressant therapy
- Overcrowding: institutions, poverty, homelessness
- Malnutrition
PACES
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