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Resp Flashcards

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1
Q

Benefits of VATS procedure over open thoracotomy

A

Video-assisted thoracoscopic surgery - small incision, so reduced pain, wound complications, healing time and length of stay

But for Pleurectomy - greater risk of recurrent pneumothorax in VATS (5%) than open (1%)

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2
Q

indications for lobectomy

A
  •  Lung cancer resection (main) - most commonly NSCLC, in RUL
  •  TB
  •  Aspergilloma (to protect from massive haemorrhage)
  •  Lung abscess
  •  Remember pleurectomy for recurrent pneumothox
  •  and Lung volume reduction surgery i.e. bullectomy
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3
Q

FEV1 for lobectomy to have good outcome

A

Good outcome if FEV1 > 1.5

> 2 for a full pneumonectomy

provided there is no ILD or disability from SOB

If not clearly operable patients should have Sats at rest and Transfer Factor (TLCO) >50

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4
Q

FEV1 for pneumonectomy to have good outcome

A

> 2 for a full pneumonectomy

> 1.5 for lobectomy

provided there is no ILD or disability from SOB

If not clearly operable patients should have Sats at rest and Transfer Factor (TLCO) >50

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5
Q

way to measure prognosis in post op lung resection

A

Stair climbing is practical way

FEV1 and VO2 max < 15ml/kg/min

..VO2max = maximal oxygen utilised during maximal exercise

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6
Q

lung cancer histology

A

Small Cell

NSCLC (80%)
Majority - Squamous & Adeno
Also - Large cell & Neuro endo

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7
Q

Most common lung cancer in non-smokers

A

Adenocarcinoma

This is also most common overall, but in smokers squamous is most common

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8
Q

Asbestos causes which cancers

A

Mesothelioma, but also bronchial carcinoma, laryngeal cancer and ovarian cancer.

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9
Q

Lung cancer with hyponatremia

A

Small cell… Occurs because of ectopic ADH secretion

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10
Q

Mx of lung cancers

A

SCLC is rapidly progressive, often presents late…
So early disease - chemoradiotherapy
Late - often palliative chemo

NCLC - could include curative surgical, +/- adjuvant chemoradio

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11
Q

normal examination findings but scar indicating a VATS

A

Could be
• Wedge resection of solitary pul nodule
• Lung biopsy
• Surgical treatment of non-resolving/recurrent pneumothorax

if RECENT lobectomy, may have deviated trachae and reduced AE

Pneumonectomy will have deviated trachae, absent breath sounds and dull perc

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12
Q

scars on VATS procedure vs open thoracotomy

A

Open thoracotomy -
• 15-20cm on lat chest wall
• may also be chest drain scar

VATS -
• 3 scars in triangle
• 3-6cm lat chest wall
• Sometimes only 2 or 1 scar apparently

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13
Q

What is Transfer Factor (TLCO) used for related to lung cancer management

A

If not clearly operable (i.e. FEV1 >2 for pneumonectomy or >1.5 for lobectomy) then TLCO

IF estimated postoperative TLCO and est postop FEV1 is high then low risk

(it measures how your lungs take up oxygen from the air you breathe)

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14
Q

Resp causes of clubbing

A
  •  Bronchogenic carcinoma (AKA any type/subtype)
  •  ILD (particularly IPF)
  •  Bronchiectasis
  •  Lung abscess/empyema
  •  CF
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15
Q

pneumonectomy vs lobectomy examination findings

A

Pneumonectomy will have deviated trachae, absent breathsounds and dull perc

Lobectomy likely to be normal or possibly reduced

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16
Q

copd inhaler management

A

FIRST
Short acting
• …beta-2 agonists, like salbutamol
• or …muscarinic antagonists, like ipratropium

SECOND
if no asthmatic/steroid responsive features:
Long acting:
• …beta-2 agonists, like salmeterol
• AND …muscarinic antagonists, like tiotroprium

If that fails, or if asthmatic/steroid responsive features, then trial inhaled corticosteroids

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17
Q

indications for VATS

A
  • Lobectomy
  • Wedge resection (i.e. cancer etc)
  • Lung biopsy (i.e. ILD, cancer)
  • Decortication (i.e. in long-standing empyema, pleural thickening, hemothorax, and pleural tumors)
  • Bullectomy (i.e. COPD)
  • Pleurectomy (recerrent pneumothoraxes)
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18
Q

Why is suction not be routinely recommended in chest drain pneumothorax?

A

Rare as risk of re-expansion pulmonary oedema

Consider if persistent air leak…arbitrarily defined as continued bubbling of air through a chest drain after 48 h in situ,,,

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19
Q

Mx of pneumothoraces if no prev history < 50yr and breathless

A

(Primary pneumothorax)
• As SOB → aspirate up to 2.5L
• if <2cm and breathing improved then consider discharge + OP review in 2-4weeks
• If not → Chest drain

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20
Q

Mx of secondary pneumothorax

A
  • Always admit
  • > 2cm OR breathless → chest drain
  • 1-2cm → aspirate
  • <1cm → admit for 24h with O2
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21
Q

Can you differentiate between a lobectomy and other indication of VATS in otherwise normal exam

A
  • IF normal chest exam, Lobectomy is less likely
  • indications for lobectomy are often smoking-related diseases

Lobectomy may have normal chest signs but likely signs related to smoking

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22
Q

Eosinophils in asthma

A

~ 40% of severe asthmatics are diagnosed with Eosinophilic asthma

Don’t respond to steroids as well so treated with MABs

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23
Q

Diurnal variation in Asthma

A

Low peak flow in night/morning

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24
Q

spirometry in asthma vs COPD

A
  • both have obstructive picture (<0.7 = reduced FEV1, preserved FVC)
  • Asthma would improve with bronchodilator (15% impr of FEV1)
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25
asthma management
1) SABA 2) Add inhaled steroid if: exacerbations in last 2yr; using salbutamol or symp 3/wk; OR waking one night/wk 3) Trial LABA (Salmeterol) +/- increasing steroid 4) Add leukotriene receptor antagonist; theophylline; slow release β2 agonist tablets 5) Oral Steroids
26
Obstructive respiratory disease
* Asthma * Bronchiectasis * COPD * Rarer...Obliterative bronchiolitis (fixed airflow obstruction, from viral, polutent, Graft vs host (like lung transplant)
27
causes of polyphonic wheeze
obstructive resp disease * COPD * Asthma * Bronchiectasis * Rarer...Obliterative bronchiolitis (fixed airflow obstruction, from viral, polutent, Graft vs host (like lung transplant)
28
bibasal crepitations
• End-inspiratory fine - ILD • Coarse-inspiratory - Bronchiectasis with periph oedema and elevated JVP - Congested HF • Bilat pneumonia
29
Spirometry findings in ILD
* Restrictive * Reduction in both FEV1 and FVC with preserved ratio * Reduced TLC and Transfer Factor
30
antifibrotic therapies for the treatment of idiopathic pulmonary fibrosis
* Pirfenidone * and Nintedanib Considered by tertiary centres if FVC 50-80%
31
Management of ILD
Conservative • MDT approach - physio - resp nurses for SOB and QOL Medical • Mx underlying connective tissue disorder w DMARD • May respond to steroids if CT shows ground glass • if IPF and FVC 50-80% then anti-fibrotic agent Surgical • Consideration of lung transplantation
32
What is HRCT
high resolution CT without contrast that gives definition to pulmonary parenchyma e.g. in pulmonary fibrosis or bronchiectasis
33
Upper Vs lower zone fibrosis
ACID causes lower, the rest upper * Asbestosis * Connective tissue disorders (except ank spond) * Idiopathic pulmonary fibrosis / usual Interstitial Pneumonia * Drugs...... (Amiodarone, bleomycin, methotrexate). ``` Upper: C - Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis ```
34
Causes of Interstitial lung disease (ILD)
* Idiopathic – IPF, or sarcoidosis * Occupational – asbestosis or silicosis * Hypersensitivity pneumonitis (ABPA, farmer's) * Connective tissue disease – RA, SLE, polymyositis * Drug-induced – Amiodarone, Nitro, Methotrexate, radiotherapy
35
When would you consider antifibrotic therapies in IPF
Considered by tertiary centres if FVC 50-80% predicted in idiopathic pulmonary fibrosis to slow disease progression (pirfenidone and nintedanib)
36
patient over 50yr with SOBOE, persistent cough OE bilat fine end inspiratory crackles, finger clubbing
Classic hx of idiopathic pulmonary fibrosis if no signs of connective tissue disease or occupational
37
Which interstitial lung disease (ILD) carries worst prognosis?
Idiopathic pulmonary fibrosis *  Median survival is 2-3 years from diagnosis *  Only 20-30% survive to 5 years
38
Poor prognosistic factors for IPF
Basically every bad feature... * Old age * Dyspnoea * Low or declining pulmonary function * Pulmonary artery HTN * Co-existing emphysema * Extensive radiographic involvement * Low ET * Exertional desat * Universal interstitial pneumonia (UIP) on histopath
39
Pt with coarse inspiratory creps and PEG tube
?CF May have a Button Gastrostomy instead Also may have clubbing Could have previous Portacath Classically upper lobe creps +/- exp wheeze
40
what gene transmits CF?
CFTR gene on Chromosome 7 ... leads to increase salt excretion
41
Can you tell me anything about the cause of cystic fibrosis?
* Auto recessive * Mutation in CFTR chr 7 Leading to increased salt excretion, therefore, thicker mucus which will affect: • respiratory system → bronchiectasis • digestive tract → pancreatic insufficiency • reproductive system → in/subfertility
42
Drug management for CF
*  Regular mucolytics nebs *  Creon and Fat soluable vitamins *  Prophylactic azithro *  Vaccines • Lumacraftor-ivacaftor (Orkambi) if homogenous ΔF508 (50% of patients are homozygous)
43
what bacteria in CF is absolute contraindication to lung transplantation?
Burkholderia cenocepacia non-tuberculous mycobacteria - Mycobacterium abscessus (carries particularly poor prognosis so is absolute contraindication)
44
CF life expectancy
~50% will live past the age of 40 as per NHS website
45
How is CF diagnosed?
All infants in UK are screened using Guthrie's test for phenylketonuria a few days after birth Previously, diagnosed following meconium ileus in infancy or failure to thrive
46
CFTR modulating therapies in CF
Lumacraftor-ivacaftor (Orkambi) can be used if homogenous delta F508 (50% of patients are homozygous)
47
commonest indications for lung transplant
COPD (most common, likely single lung) Bronchiectasis (including CF) Pulmonary fibrosis (likely single) Pulmonary hypertension (may need heart-lung transplant)
48
Double lung transplant vs single
``` Better prognosis (7.5yr median survival vs 4.5) ( most likely in Bronchiectasis e.g. CF ) ```
49
indications for heart-lung transplant?
severe pulmonary hypertension
50
Complications of lung transplant
ACUTE PHASE • acute rejection (most pt will experience at least once in first 6/12) • opportunistic infections CHRONIC PHASE • Bronchiolitis obliterans - usually a terminal event - >50% will develop some degree of BO 5y post-trans • Cancer - post transplant lymphoproliferative disorder most common in first year/ skin malig • Steroid SE • Tacrolimus → diabetes, tremor • Renal and hearing impairment from anti-rejection agents
51
contraindications to lung transplant
* Malignancy in last 5yr (or 2yr if low risk of recurrence) * BMI >35 * Current smokers or substance abuse * Mental Health conditions that would preclude taking meds or attending clinic * Untreatable heart liver kidney or brain dysfunction * Atherosclerotic disease w end organ ischaemia
52
Criteria to consider lung tranplant in end stage lung disease
>50% chance of death within 2yr >80% chance of surviving >90 days post transplant >80% 5yr post tranplant survival from gen med perspective (sick enough to need one, fit enough to survive, with no major comorbs)
53
When to consider lung transplant in CF
* Poor ET * Frequent exacerbations * FEV1 < 30% * Signif pulmonary artery hypertension
54
Which lung condition carries the best post-transplant survival
CF
55
Causes of increased vocal fremitus
* Pneumonia * hyperinflation like COPD asthma * Lung abscess
56
Causes of decreased vocal fremitus:
* Pleural effusion * Pneumothorax * Emphysema
57
yellow nail syndrome triad
* Yellow nail discoloration * Pulmonary - bronchiectasis, pleural effusion * Lower limb lymphedema Chronic sinusitis is frequently associated with the triad.
58
Causes of bronchiectasis
Bronchiectasis can be idiopathic (40%) Other causes can include: • Bronchiectasis can be idiopathic (40%) • Recurrent infections Alcoholics/asp pneumonia • childhood infections – , TB, measles • Hypersensitivity - Allergic bronchopulmonary aspergillosis • Inherited - CF, primary ciliary dyskinesia
59
Tell me about Allergic bronchopulmonary aspergillosis (ABPA)
a hypersensitivity response to the fungus Aspergillus (most commonly Asp fumigatus) causes bronchiectasis Common in CF and asthma
60
Dextracardia and chronic productive cough
Primary ciliary dyskinesia • autosomal recessive genetic ciliary disorder • Diagnose with ciliary function tests - can they taste saccharin 20m after placed in nose?! OR if full situs invertus: Kartagener's syndrome • autosomal recessive genetic ciliary disorder • situs inversus, chronic sinusitis, and bronchiectasis
61
Diagnosis of Allergic bronchopulmonary aspergillosis (ABPA)
* Aspergillus skin test (AST) * Elevated IgE (Total, and specific serum to A. fumigatus) * Baseline CXR * HRCT
62
respiratory causes of raised JVP
COPD or ILD Chronic hypoxia leads to pulmonary vasoconstriction,then pulmonary hypertension, causing R heart failure
63
Hypertrophic pulmonary osteoarthropathy
* periostitis * digital clubbing * painful arthropathy of the large joints (particularly lower limbs)
64
How would you do a biopsy for ?Lung cancer
``` Biopsies may be made via • bronchoscopy • endobronchial ultrasound • percutaneously (under radiology) • mediastinoscopy ``` LN also biopsied or FNA Pleural effusions should undergo diagnostic pleural aspiration
65
Causes of unilateral pleural effusion
``` Likely exudative • Lung malignancy • Infection (parapneumonic, empyema) • Infarction e.g. due to pulmonary embolus • Inflammation: RA and SLE ```
66
Causes of bilat pleural effusion
Likely Transudative • Cardiac failure • Liver failure - cirrhosis / hypoalbuminemia • CKD
67
How to distinguish between transudative and exudative pleural effusion?
Light’s criteria on a pleural aspirate. Exudate if one or more of: • pleural fluid : serum Protein ratio is > 0.5 • pleural fluid : serum LDH ratio is > 0.6 • pleural LDH >2/3 the upper limit of normal for the serum LDH pH < 7.1 also suggests an exudate
68
In pleural effusion, when would you drain?
• Symptomatic Signs it is parapneumonic • Pleural pH <7.2 is most important (or high LDH and low glucose, but less accurate) • Purulent or turbid/cloudy • Positive culture
69
Most likely diagnosis in pneumonectomy
NSCLC for both pneumonectomy and lobectomy
70
What drug treatments are used for interstitial lung disease?
For idiopathic pulmonary fibrosis: • Pirfenidone • Nintedanib For patients with non-specific interstitial pneumonia/ground glass shadowing: • Steroids • Immunosuppressive therapy
71
COPD classification of severity
``` FEV1 compared to predicted • >80% mild • 50-80% moderate • 30-50% severe • <30% very severe ```
72
Pt with rheumatoid arthritis who presents with respiratory disease
* ILD * bronchiectasis directly from RA, or from infections related to immunosuppression * obliterative bronchiolitis (this is obstructive, and rare)
73
CXR sarcoidosis
Stage 0 - no abnormalities (5-10%) Stage 1 - Bilateral hilar lymphad (50%) Stage 2 - Bilateral hilar lymphad + pulmonary infiltrates (25-30%) Stage 3 - Diffuse pulmonary infiltrates (10-12%) Stage 4 - Pulmonary fibrosis 5%
74
Treatment for sarcoidosis
Mostly supportive only If severe symptoms or CXR of stage 2 or above, use systemic steroids Methotrexate or anti TNF therapies can be used
75
What is sarcoidosis
A granulomatous disorder that affects multiple organs | Cause is not known
76
Diagnosis of sarcoidosis
transbronchial biopsy +ve in 90%
77
pulmonary function tests in sarcoidosis
restrictive | decreased TLCO gas transfer
78
Distinguish between bronchiectasis and ILD
Both have Fine creps , but they shift following a cough with bronchiectasis ILD -restrictive Bronch -obstructive (both can have clubbing)
79
PE Wells score
``` 4 points (PE likely) • DVT +3 • PE is top diagnosis +3 • Tachy > 100 +1.5 • Immobilisation >3d OR surgery in 4w +1.5 • Previous PE/DVT +1.5 • Hemoptysis +1 • Malignancy +1 ```
80
DVT Wells score
>= 2 likely * Malignancy * Immobilisation >3d OR surgery in 12w * Calf swelling (>3cm) * Superficial veins * Entire leg swollen * Localised tenderness along the deep venous system * Unilateral pitting oedema * Paralysis, paresis, or recent plaster immobilization of the lower extremity * Previous DVT * Alternative diagnosis (-2)
81
Prolonged expiratory phase
Indicates obstructive picture • COPD • Asthma • Bronchiectasis (ILD is restrictive)
82
Counselling for Patient with TB
``` 4 antibiotics 6m of treatment SE Liver Avoid alcohol Check HIV etc ``` Isolation if multidrug-resistant TB until sputum becomes negative Can force to keep under Public Health Act 1984
83
Signs of Superior Vena Cava Obstruction
* Dilated veins over the arms, neck and anterior chest wall * Oedema of the upper body, extremities and face * Severe respiratory distress Exacerbated by Pemberton's sign
84
Causes of Superior Vena Cava Obstruction
* Bronchiogenic carcinoma * NSCLC * SCLC lymphoma and germ cell tumours responsible for a smaller but significant proportion
85
Differential causes of obliterative bronchiolitis
* Granulomatous polyarteritis (previously Wegner’s): saddle nose; obliterative bronchiolitis * Rheumatoid arthritis: wheeze secondary to obliterative bronchiolitis * Post‐lung transplant: obliterative bronchiolitis as part of chronic rejection spectrum
86
indications for LTOT
* Non‐smoker * PaO2 <7.3kPa on air * PaCO2 that does not rise excessively on O2 7.3-8 if: • secondary polycythaemia • pulmonary hypertension • peripheral oedema
87
causes of COPD
* Smoking * industrial dust exposure * Alpha1 antitrypsin (basal disease)
88
Obstructive spirometry
FEV1/FVC < 0.7
89
mechanism behind CO2 retainers
In COPD, pt optimise their gas exchange by hypoxic vasoconstriction leading to altered alveolar VQ ratios Excessive O2 causes increased blood flow to poorly ventilated alveoli, increasing VQ mismatch
90
Management of Pulmonary hypertension
* Treat any underlying causes * Prostacyclin analogues * Endothelin-A receptor antagonists * Phosphodiesterase-5 inhibitors
91
Pulmonary hypertension causes
* Idiopathic * Drug/toxin-induced * portal hypertension * HIV * Chronic hypoxia * Congenital HD * Systemic sclerosis, SLE , RA , Sjogren's
92
What is bronchiectasis
long-term condition where the airways of the lungs become widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection
93
Cor pulmonale
RHF secondary to respiratory disease (chronic hypoxia -> pul vasoconstriction -> pulmonary hypertension) Main treatment is oxygen therapy / diuretics
94
SOB without signs
* Anaemia * Cancer * PE * Obesity hypoventilation
95
Management for bronchiectasis
* smoking cessation * vaccines * postural drainage * abx / prophylactic * Bronchodilators Can consider lung resection /transplant if FEV1 below 30% of predicted
96
Treatment of cor pulmonale
LTOT
97
Cor pulmonale signs
* Raised JVP * Peripheral oedema * Loud S2 * RV heave * S3 gallop * displaced/thrusting apex
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