Clinical signs of pulmonary fibrosis
Inspection: clubbing, central cyanosis, tachypnoea
Auscultation: fine end-inspiratory crackles which do not alter with coughing
Signs of associated AI disease e.g. RA, SLE, systemic sclerosis
Signs of treatment e.g. Cushingoid
Discoloured grey skin - amiodarone as cause
Investigations for pulmonary fibrosis
Bloods: ESR, RF, ANA
CXR: reticulonodular changes, loss of definition of heart borders, small lungs
ABG: type I respiratory failure
Lung function tests: FEV1/FVC >0.8 (restrictive), low TLC (small lungs)
Bronchoalveolar lavage: exclude infection prior to immunosuppressant use)
HRCT: distribution aids diagnosis
Lung biopsy
Treatment for pulmonary fibrosis
If inflammatory –> immunosuppression (steroids)
If UIP - pirfenidone (antifibrotic agent)
Single lung transplant
Causes of basal lung fibrosis
Usual interstitial pneumonia (UIP)
Asbestosis
Connective tissue disease
Aspiration
Clinical signs for bronchiectasis
Room: sputum pot +++
Gen: cachexia and tachypnoea
Hands: clubbing
Chest: mixed character crackles that alter with coughing, occasional squeaks and wheeze
Cor pulmonale: SOB, raised JVP, RV heave, loud P2
Investigation for bronchiectasis
Sputum culture and cytology
CXR: tramlines and ring shadows
HRCT thorax: signet ring sign (thickened dilated bronchi larger than adjacent vascular bundle)
To find specific cause:
Immunoglobulins - hypogammaglobulinaemia
Aspergillus RAST/skin prick testing - ABPA (upper lobe)
Rheumatoid serology
Saccharine ciliary motility test (nose to taste buds in 30mins) - Kartagener’s
Genetic screening - CF
Hx of IBD
Causes of bronchiectasis
Congenital: Kartagener’s and CF
Childhood infection: measles and TB
Immune OVERactivity: ABPA and IBD associated
Immune UNDERactivity: hypogammaglobulinaemia, CVID
Aspiration: chronic alcoholics and GORD, localised to right lower lobe
Treatment for bronchiectasis
Physio - active cycle breathing
Prompt abx therapy for exacerbations
Long-term treatment with low-dose azithromycin 3x week
Bronchodilators/inhaled corticosteroids if airflow obstruction
If localised –> surgery
Complications of bronchiectasis
Cor pulmonale Secondary amyloidosis (dip urine for protein) Massive haemoptysis (mycotic aneurysm)
Clinical signs of old TB
Inspection:
- chest deformity and absent ribs
- thoracotomy scar
Palpation:
- tracheal deviation towards the side of the fibrosis
- reduced expansion
Percussion:
-dull percussion but present tactile vocal remits
Auscultation:
-crackles and bronchial breathing
Historical techniques to treat TB
Plombage: insertion of polystyrene balls into the thoracic cavity
Phrenic nerve crush: diaphragm paralysis
Thoracoplasty: rib removal but lung not resected
Apical lobectomy
Serious side effects of TB drugs
Rifampicin: hepatitis, increased metabolism of OCP
Isoniazid: peripheral neuropathy (treat with pyridoxine) and hepatitis
Pyrazinamide: hepatitis
Ethambutol: retro-bulbar neuritis and hepatitis
What to tell patients about to commence TB therapy
- If your eyes become yellow, stop tablets and ring nurse immediately
- If reds begin to appear less red, ring nurse
- If you develop tingling in your toes, continue tablets but tell them at your next clinic visit
- Your secretions will turn orange/red. Don’t wear contact lenses
- OCP may fail, use barrier contraception
Causes of apical fibrosis
TRASH
- TB
- Radiation
- Ankylosing spondylitis/ABPA
- Sarcoidosis
- Histoplasmosis/ hypersensitivity pneumonitis
Clinical signs of lobectomy
Inspection:
- Chest wall deformity
- Thoracotomy scar - same for either lower or upper lobe
Palpation:
- Trachea is central
- Reduced expansion
Lower lobectomy: dull percussion note over lower zone + absent breath sounds
Upper lobectomy: normal exam OR hyper-resonant percussion note over upper zone and dull percussion at base where hemidiaphragm has lifted
Clinical signs of pneumonectomy
Inspection:
-Thoracotomy scar
Palpation:
- Reduced expansion on side of pneumonectomy
- Trachea deviated towards the side of the pneumonectomy
Percussion:
- Dull percussion note throughout hemithorax
- Absent tactile vocal fremitus beneath thoracotomy scar
Auscultation:
- Bronchial breathing in upper zone
- Reduced breath sounds throughout remainder of hemithorax
Clinical signs of single lung transplant
Thoracotomy scar
Normal exam on side of scar
May have signs on opposite hemithorax
Clinical signs of double lung transplant
Clamshell incision - from on axilla, along line of lower ribs, up to the xiphisternum to other axilla
Indications for single lung transplant
‘Dry lung’ conditions: COPD, pulmonary fibrosis
Indications for double lung transplant
‘Wet lung’ conditions: CF, bronchiectasis, pulmonary hypertension
Clinical signs of COPD
Inspection:
- Nebulizer/inhalers/sputum pot
- Dyspnoea, central cyanosis, purses lips
- CO2 retention flap, bounding pulse, tar stained fingers
Palpation:
-Hyperexpanded
Percussion:
-Resonant with loss of cardiac dullness
Auscultation:
- Expiratory polyphonic wheeze
- Reduced breath sounds at apices
Clinical signs of cor pulmonale
- Raised JVP
- Ankle oedema
- RV heave
- Loud P2 with pan systolic murmur (TR)
Investigations for COPD
ABG: type II respiratory failure
Bloods: high WCC (infection), low A1AT (younger patients/FH), low albumin (severity)
CXR: hyper-expanded and/or pneumothorax
Spirometry: low FEV1, FEV1/FVC <0.7 (obstructive)
Gas transfer: low TLCO
Possible COPD treatments
- Smoking cessation (clinics and nicotine replacement therapy)
- Pulmonary rehabilitation
- Exercise
- Nutrition
- Vaccinations: pneumococcal and influenza
- Mild (FEV1>80%): beta-agonists
- Mod (<60%): above + tiotropium
- Severe (<40%): above+ inhaled corticosteroids
-Long-term oxygen therapy: 2-4L/min via nasal prongs for at least 15hrs a day
Surgical:
- Bullectomy
- Endobronchial valve placement
- Lung reduction surgery
- Single lung transplant
