Causes of consolidation
Pneumonia
Pulmonary haemorrhage
Malignancy
Pulmonary oedema
Signs of COPD
- CO2 retention tremor
- Hyperexpanded ‘Barrel’ chest
Signs of pneumothorax
- Tracheal deviation (away from side)
- Reduced chest expansion
- Hyper-resonance on percussion
- absent breath sounds
Signs of lobar collapse/lobectomy
- Trachial deviation (towards side)
- Reduced expansion
- Absent breath sounds
Indications for lobectomy
- Cancer
- Trauma
- Bronchiectasis (lung volume reduction)
- TB
Signs of pleural effusion
- Reduced expansion
- Stony dull percussion
- Reduced breath sounds
Signs of consolidation
- Reduced expansion
- Dull percussion
- Bronchial breathing on auscultation
- Coarse crackles
Causes of interstitial lung disease
Inhaled antigen (organic)
- Bird fancier’s lung
- Farmer’s lung
Inhaled irritant (inorganic)
- Asbestosis
- Pneumoconiosis e.g. Coal miner’s lung
- Silicosis
Idiopathic
Associated with systemic disease
- RA
- SLE
- Sarcoidosis
Iatrogenic
- Methotrexate
- Amiodarone (basal fibrosis)
Interstitial lung disease Mx
Conservative
- Chest physiotherapy
- Pneumococcal and flu vaccines
- Stop smoking
- Stop causative medications
Surgical
- Lung transplantation
Spirometry interpretation
Predicted FEV1/FVC ratio can be calculated based on age, height, sex, ethnicity
FEV1/FVC normal = 80%
FEV1/FVC ratio <0.7 = obstructive airway disease (both FEV1 and FVC reduced, FEV1 more drastically) - FEV1 determines severity
FEV1/FVC ratio >0.7 = restrictive airway disease (both reduced, FVC more than FEV1) - TLC determines severity
Causes of coarse crackles
Aspiration
Pneumonia
Pulmonary oedema
Causes of fine crepitations
Interstitial lung fibrosis
Additional airway sounds
Pleural rub (rubbing sound heard on inspiration) Wheeze (polyphonic or monophonic) Fine crepitations (late inspiratory) Coarse crepitations (early inspiratory)
Chronic asthma Mx
MDT
Conservative Avoid triggers Inhaler technique Regular asthma review No smoking Flu vaccines
Medical SABA + ICS SABA + ICS + LRTA SABA + ICS + LABA (stop LRTA if ineffective) SABA + (ICS + LABA) = (MART) Increase ICS dose Specialist referral
Causes of bronchiectasis
A1 antitrypsin deficiency Systemic disease e.g. RA Severe respiratory infections e.g. TB CF PCD
COPD classification based on FEV1 percentage predicted
50-79%: Mild
30-49%: Moderate
Less than 30%: Severe
Stable COPD Mx
Conservative
- Pulmonary rehabilitation
- Pneumococcal and flu vaccines
- Stop smoking
Medical
- SABA or SAMA
- SABA + LABA + ICS (if steroid responsive)
- SABA + LABA + LAMA+ ICS
- Specialist referral
- SABA + LABA + LAMA (if not steroid responsive)
- SABA + LABA + LAMA + ICS
- Specialist referral
- LTOT
- Prophylactic antibiotics (azithromycin - if multiple exacerbations)
LTOT criteria
Have a PaO2 < 7.3 kPa Have a PaO2 7.3 - 8 kPa and one or more of the following: ® Secondary polycythaemia ® Peripheral oedema ® Pulmonary hypertension
Ix for interstitial lung disease
Bedside
PEFR
Spirometry
Bloods
FBC, U&Es
Antibody screen - Anti-CCP, RF, dsDNA
Imaging
High resolution CT chest
CXR
Lung biopsy (diagnostic, not normally done)
Types of lung cancer and paraneoplastic syndromes
Small cell carcinoma (ACTH, SIADH, LEMS) - Associated with smoking
Non-small cell carcinoma
- Large cell carcinoma
- Lung adenocarcinoma (most common in non-smokers)
- Squamous cell carcinoma (PTHrp) - associated with smoking, most common
Lung cancer Ix
Bloods
Imaging
CXR
2ww CT PET
Interventional
EBUS- guided biopsy
2ww criteria for lung cancer
Presenting symptoms for CXR: Cough SOB Fatigue Weight loss Chest pain Appetite loss
Refer if:
Over 40 + 2 symptoms
Smoker + 1 symptom
Lung cancer Mx
Conservative
MDT (Macmillan, psych support)
Smoking cessation
Chemotherapy (especially for small cell carcinoma)
Radiotherapy
Lobectomy
Pneumonectomy
NSCLC: Surgery (20% suitable) or curative/palliative radiotherapy
SCLC: Surgery (early disease), Chemoradiotherapy (advanced disease)
TB drug SEs
Rifampicin: Orange secretions
Isoniazid: Peripheral neuropathy, Liver injury
Pyrazinamide: Liver injury
Ethambutol: Visual disturbance
