Clinical diagnosis of hyper expansion
Reduced cricosternal distance
Loss of cardiac dullness
Palpable liver edge
Pathophysiology of COPD
Chronic bronchitis / bronchiectasis with emphysema
Chronic bronchitis - cough productive of sputum on most days >3mo on consecutive years
Emphysema - histological alveolar wall destruction with airway collapse and air trapping
COPD - investigations
Bedside - PEFR, BMI, sputum MC+S
Lung function - spirometry obstructive (increased TLC and RV, FEV1:FVC <0.7, FEV1 <80% predicted
Blood - FBC, ABG (TIIRF), CRP, albumin, a1 AT levels if FH and young
Imaging - CXR, Echo (cor pulmonale), ECG
mMRC dyspnoea score
- SOB on vigorous exertion
- SOB on hurrying / stairs
- Walks slowly or has to stop for breath
- SOB <100 yrd / few min
- Too breathless to leave house
COPD exacerbation - scale
Mild - FEV1 >80% but FEV1/FVC <0.7
Mod - FEV1 50-79%
Sev - FEV1 30-49%
V. Sev - FEV1 <30%
COPD management
Principal therapies: LAMA/SAMA, SABA/LABA, corticosteroids
Other: theophylline, carbocysteine (mycolytic)
Home emergency pack
LTOT: aim PaO2 >8 for >15h/day, but be non smoker
Mx Acute Exacerbation COPD
- Controlled O2: sit up, 24% O2 venturi mask target SpO2 88-92%. Aim PaO2 >8 and increased in PCO2 of no more then 1.5 kPa
- Nebulised (air driven): Salbutamol 5mg/4h; Ipratropium 0.5mg/6h
- Steriods: Hydrocortisone 200mg IV; Pred 40mg PO 7-14d
- Abx: Doxy 200mg PO STAT + 100mg OD PO 5/7
- Consider aminophylline IV
- Consider NIV
Asthma: Ix
Bedside: PEFR Blood: FBC (eosinophilia), IgE, CXR: hyperinflation Spirometry: obstructive (reduced FEV1, increased RV, improvement with B agonist trial) PEFR diary: diurnal variation Atopy: skin sprick test, RAST
Severe asthma attack
PEFR <50%
Can’t complete sentence in one breath
RR >25
Hr >110
Life threatening asthma attack
PEFR <33% SpO2 <92%, PCO2 >4.6 kPa, PaO2 <8kPa Cyanosis Hypotension Exhaustion / Confusion Silent chest, poor resp effort Tachy/brady/arrythmias
Acute Asthma Attack: Mx
- Sit-up, 100% O2 via non-rebreathable mask (aim 94-98%), nebulised salbutamol 5mg and ipratropium 0.5mg, hydrocortisone 100mg IV
- ?Inform ITU, MGSO4 2g IVI over 20 min, nebulised salbutamol every 15min (monitor ECG)
- If improving: monitor SaO2, PEFR, continue pred 50mg OD 5/7; nebulised salbutamol /4hrs
- If no improvement: nebulised salbutamol /15min, continue ipratropium 0.5mg 4-6hrs, MgSO4 2g IVI over 20 min, salbutamol IVI 3-20ug/min), consider aminophylline, ITU
DDx pulmonary fibrosis
Upper: aspergillosis, pneumoconiosis (coal, silica), extrinsic allergic alveolitis, TB
Lower: sarcoid, toxins, aspestosis, IPF, RA, SLE, SS, Sjogren’s
Drugs –> Bleomycin, Amiodarone, Nitrofurantoin, Sulfasalazine, Methotrexate
Ix Pulmonary Fibrosis
Bedside: PEFR, ECG (RVH) Blood: FBC (anaemia), ABG, ESR/CRP (+ IPF), ANA (30%), RF (10%) CTD: C3/C4, CCP, scl-70, centromere Sarcoid: ACE, Ca CXR / HRCT (firbosis, honeycomb) Spirometry: restrictive
IPF: Mx
MDT Smoking cessation LTOT Pulmonary rehab Symptoms: Anti tussives (codeine), CCF Surgical: Lung Tx
Causes of bronchiectasis
Congenital: CF, PCD/Kartagener’s, Hypogammaglobulinaemia
Acquired: Idiopathic, post infectious (TB, pertussis, measles), obstruction (FB, tumour), other (RA, IBD, amyloidosis)
Bronchiectasis Ix
Bedside: PEFR, dipstick, sputum MC+S
Blood: FBC, serum Ig, FR/antiCCP
CXR - tramlines and ring shadows (bunch of grapes)
HRCT - signet ring sign (thickened dilated bronchi + smaller adjacent vascular budge
Spirometry - obstructive
Bronchoscopy + biopsy
CF: pathophysiology
1/25 carrier, AR d508 CFTR chr 7 Decreased luminal Cl secretion and increased Na reabsorption leads to very viscous secretions = bronchiectasis, DM, malabsorption, gallstones/cirrhosis, infertility Sweat test = pilocarpine + Na/CL >60mM Immunoreactive trypsinogen (neonates), faecal elastase (pancreatic exocrine function)
CF pt: Mx
MDT Physio Abx Mucolytics Vaccination Heart lung Tx Creon + ADEK supplements ± Insulin Fertility DEXA
Kartagener’s syndrome triad
Situs inversus + Chronic sinusitis + Brnochiectasis
Young’s Syndrome triad
Bronchiectasis + Rhinosinusitis + Azoospermia
Light’s criteria for Exudative Effusion
Effusion:serum protein ratio >0.5
Effusion:serum LDH ratio >0.6
Effusion LDH =0.6xULN
Complications of Lung Ca
Invasion: SVCO, RLNP, Pancoast, dermatomyositis
Paraneoplastic
Pneumonectomy vs Lobectomy
Lateral thoracotomy scar - look
Pneumonectomy: tracheal + apex shift to abnormal side - reduced expansion, dull percussion, NO breath sounds
Lobectomy: tracheal shift to abnormal side, reduced expansion, dull percussion, reduced breath sounds
Indications: 90% non-disseminated bronchial Ca, bronchiectasis, COPD, TB
Lung Ca: pathology
NSCLC 80% (SCC 35%, smokers, central, ++Ca; AC 25%, F, non smokers, peripheral, 80% present mets; LCLC 10%
SCLC 20% (Highly related to smoke, central, paraneoplastic)
