bilateral hilar lymphadenopathy - most common causes and others
sarcoidosis and TB
but remember lymphoma and pneumoconiosis
Lung cancer ix - options and findings
CXR is first line in suspected lung cancer (although normal CXR in 10%)
- cT chest useful. should always be done if still suspecting after -ve CXR
- US and bronchoscopy for histology
- PET CT - useful to see if NCSLC is operable, more is taken up by cancer
- bloods: raised plts
asthma management in adults - stepwise management
- if not acute then AIR, anti-inflammatory reliever. this is ICS/ formeterol used only as reliever
OR if acute: low dose MART. this is ICS/ formeterol inhaler used as maintenance and reliever
- low dose MART
- moderate dose MART
- check FENO and eosinophils. if low try MART plus LTRA or then LABA. if high refer to specialist
- if moderate dose MART/ LTRA/ LABA don’t help -> specialist time
stable COPD management - general management, risks of medication, antibiotic in depth, cor pulmonale and management
gen: stop smoking, annual flu, one-off pneumococcal, pulm rehab
- SABA or SAMA
- are there asthmatic features? raised eosinophils, diurnal variation, FEV1 variance of 400, previous asthma diagnosis
- if yes SABA, LABA + ICS
- if no SABA, LAMA + LABA - LABA + LAMA + ICS
other management: LTOT, abx, mucolytics, lung volume reduction surgery, theophylline, PDE-5i like roflumilast
risks: ICS increases risk of penumonia
abx: prophylatic azithromycin if CT doesn’t show bronchiectasis, culture doesn’t show atypical, stopped smoking, ECG doesn’t show prolonged QT, normal LFT’s
cor pulm: oedema, parasternal heave. manage with loop diuretics
atelectasis - what is it, features, management
often post op, big abdo ops means that patients don’t breathe well due to pain. secretions get stuck and cause bibasal alveolar collapse
low sats, breathless. 72 hours post op
mx: sit upright, chest physio. early mobilisation and analgesia post op
pneumothorax - classification, clinical features
primary - tall thin men
secondary - COPD, other lung disease
tension - pushing medstinum, risk of arrest
iatrogenic - chest drains, NIV
one can happen to women with endometriosis in their lungs - catamenial
traumatic - penetrating/ blunt injury
inspiratory chest pain, sudden onset desaturation
pulmonary function tests - give examples of obstructive and restrictive lung disease, difference in testing
obstructive - asthma, COPD, bronchiectasis.
normal FVC, reduced FEV1
reduced fev1:fvc
restrictive - sarcoid, fibrosis, neuromuscular
very reduced FVC, reduced FEV1
normal/ high FEV1:FVC
respiratory alkalosis - what is it, causes
low pCO2, high pH
PE, anxiety, pregnancy, CNS problems, salicylate overdose at first, altitude
idiopathic pulmonary fibrosis - what is it, RF, features, ix and diagnosis, mx, prognosis
fibrosis is typically causes by meds, asbestos. IPF when no obvious cause
men, late middle age
features - progressive SOB, dry cough, clubbing, fine end inspiratory crackles
ix: restrictive picture (low FVC and high FEV1:FVC), reduced TLCO, some raised ANA, CT progresses from ground glass to honeycombing.
diagnosis: high res CT
mx: pulm rehab, pirfenidone (anti-fibrotic) and nintedanib, supplementary oxygen and rehab.
poor prognosis: 3-4 years survival
alpha-1 antitrypsin deficiency - pathophysiology, genetics, features, ix, mx
deficiency of protease inhibitor causes copd in young and non smokers
located on chromosome 14, inherited in autosomal recessive/ co-dominant fashion
features: COPD, obstructive picture, emphysema in bases on CT, PiZZ genotype, liver cirrhosis, HCC, in children you see cholestasis
ix: spirometry, A1AT levels
mx: genetic counselling ( can do pre-natal testing), avoid smoking and noxious substances, A1AT IV, and then support as you would COPD (inhalers, lung volume reduction)
mesothelioma - what is it, features, basics of mesothelioma, ix, mx, prognosis
cancer of the mesothelial cells of the pleura, limited exposure to asbestos can cause it 40 years later
features - dyspnoea, clubbin, weight loss, cough, known asbestos exposure
mesothelioma - right lung more commonly affected, mets to other lung and peritoneum common
ix: pleaural CT, X ray will show pleural thickening, painless pleural effusion (do cytology), thoracoscopy under LA, image guided pleural biopsy
mx: symptomatic, compensation, consider chemo and surgery
prognosis: very poor, median is one year of survival
asthma - stepping down treatment.
reduce ICS by 25 -50% at a time
acute exacerbations of COPD - causes, mx of non severe, mx points for severe.
typically h. influenzae
if virus it is human rhinovirus
non severe - increase puffs, pred 30mg for 5 days, abx only if purulent sputum (if so clar, amox, doxy)
severe
- o2 with 28% 4L venturi, titrate 88-92 and only increase if normal pCO2
- neb salbutamol and ipratropium
- theophylline
- IV hydrocortisone
- NIV if pH 7.25 - 7.35
paraneoplastic features of lung cancers
small cell - ADH, ACTH, lambert-eaton
squamous cell - PTH related protein (causes hypercalcaemia), painful bone(hypertrophic pulmonary osteoarthropathy), clubbing, high TSH
adenocarcinoma - painful bone, gynaecomastia
acute asthma - moderate, severe, life-threatening, near fatal///mx, criteria for discharge
moderate: 50-75%
severe: no sentences, hr > 110, rr > 25, 33-50
life threatening: <33, 92, cyanosis, hypotension, exhaistion, silent chest, brady
near fatal : normal or elevated pCO2
mx
- oxygen
- salbutamol neb
- pred 40mg for 5 days or until resolved
- ipratropium
- mag sulphate
- aminophylline under senior
- escalate: ITU for intubation/ ventilation and ECMO
24 hour puff free, PEFR> 75, checked and documented inhaler use
copd ix and diagnosis
onsidering a diagnosis of COPD in patients over 35 years of age who are smokers or ex-smokers
post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%
chest x-ray: hyperinflation, bullae, flat hemidiaphragm. Also important to exclude lung cancer
full blood count: exclude secondary polycythaemia
body mass index
mild, mod, severe and very severe is FEV1 >80, 80-50, 30-50, <30. FEV1:FVC is always < 0.7
