1
Q
What are the differentials for cough?
A
Acute - pneumonia, LRTI, bordetella pertussis, infection
Chronic - post-infective, asthma, COPD, bronchiectasis, cystic fibrosis, TB, lung cancer
Other - allergies, cold air, foreign body, GORD
ACEi, heart failure
2
Q
Differentials for haemoptysis
A
- Vasculitis
- Acute/chronic bronchitis
- Pulmonary TB
- Lung abscess
- Pneumonia
- Bronchiectasis
- Foreign body
- Anticoagulant
- Primary lung cancer
- Lung mets
3
Q
Pulmonary differentials for dyspnoea
A
Pulmonary embolism
Pneumonia
Pneumothorax
Asthma exacerbation
COPD exacerbation
Pleural effusion
Lung cancer
Interstitial lung disease
4
Q
Pulmonary differentials for chest pain
A
- Pneumothorax
- Pulmonary embolism
- Pneumonia
5
Q
What is asthma?
A
Chronic inflammatory condition of airways that causes episodic exacerbations of bronchoconstriction
6
Q
Risk factors for asthma
A
- Personal history of atopy eczema, hayfever, food allergies
- Family history of asthma/atopy
- Obesity
- Inner-city environment
- Premature birth and associated LBW
- Socio-economic deprivation
- Respiratory infections in infancy
- Exposure to tobacco smoke/inhaled particulates
7
Q
Triggers for asthma
A
- Viral respiratory infection
- Night time or early morning
- Exercise
- Allergen or irritant exposure: animals, dust
- Changes in weather: Cold/damp
- Strong emotions/ laughter
- NSAIDs/ BB
8
Q
Presentation of asthma
A
- Intermittent dyspnoea
- Dry cough (esp nocturnal)
- Tight chest
- Sx worse at night/early morning
- Bilateral widespread ‘polyphonic’ wheeze
9
Q
Red Flags for asthma
A
- Failure to thrive
- Unexplained clinical findings (focal signs, abnormal voice/cry, dysphagia, inspiratory stridor)
- Symptoms present from birth
- Excessive vomiting or posseting
- Evidence of severe upper RTI
- Persistent wet or productive cough
- FHx of unusual chest disease
- Nasal polyps
10
Q
Investigations for asthma
A
- Spirometry with bronchodilator reversibility
- FEV1/FVC <70% indicates airway obstruction
- Improvement in FEV1 with bronchodilator >12% is positive - Fractional exhaled nitric oxide (all patients aged >17)
- 35 ppb or higher with positive peak flow variability and obstructive spirometry with positive bronchodilator reversibility
- FeNO test for children 5-16 if normal spirometry or obstructive spirometry with negative bronchodilator reversibility - peak flow variability with diary for 2 weeks
- >15% improvement in FEV1/PEFR following inhalation of bronchodilator
11
Q
Medical management of asthma
A
- Short-acting beta 2 agonist inhaler (salbutamol)
- Low dose inhaled corticosteroid (prednisolone/ beclomethasone)
o Used inhaled SABA 3x a week or more
o Asthma Sx 3x a week or more
o Woken at night by asthma Sx once weekly or more - Long acting beta 2 agonist (salmeterol)
- Increase dose of ICS
- Leukotriene receptor antagonist (montelukast)
- Inhaled long acting muscarinic antagonists (tiotropium)
- Oral theophylline
- Add oral corticosteroid
12
Q
Complications of asthma
A
- Pneumonia
- Pulmonary collapse
- Impaired QoL = fatigue, underperformance at school
- Steroid use = oral/oesophageal candida, iatrogenic Cushing’s
- Status asthmaticus = Life-threatening exacerbation
13
Q
What is COPD?
A
Non-reversible long-term deterioration in airflow through lungs caused by damage to lung tissue involving airway obstruction, chronic bronchitis and emphysema
14
Q
What can cause COPD?
A
- Cigarette smoking
- Chronic exposure to pollutants at work mining, building and chemical industries
- Outdoor air pollution
- Inhalation of smoke from biomass fuels (heating/cooking in poorly ventilated areas)
15
Q
How does COPD present?
A
- Productive cough with white or clear sputum
- Wheeze
- Breathlessness
- Sx worsened by cold or damp weather and atmospheric pollution
- Depression
- Weight loss
- Hypertension
- Reduced muscle mass with general weakness
- Prolonged expiration
- Chest expansion poor
- Lungs hyper inflated = barrel chest
- Pursed lips on expiration = help prevent alveolar and airway collapse
16
Q
What is shown on spirometry in COPD?
A
o FEV <80% predicted
o FEV1/FVC <0.7 = airway obstruction
o Multiple peak flow measurements to exclude asthma
17
Q
What is shown on CXR in COPD?
A
o normal/hyper inflated lungs
o long narrow heart shadow
o reduced peripheral lung marking and bullae
o Flattened hemidiaphragms
18
Q
What is the MRC dyspnoea scale for COPD?
A
- Not troubled by breathless except on strenuous exercise
- SoB when hurrying on a level or when walking up slight hill
- Walks slower than most people on level, stops after mile or so, stops after 15 mins walking at own pace
- Stops for breath after walking 100 yards or after few mins of level ground
- Too breathless to leave house or breathless when dressing/undressing
19
Q
Medical management of COPD
A
- 1st line = SABA (salbutamol) or short acting antimuscarinics (ipratropium bromide)
- 2nd line (not asthmatic/steroid responsive) = LABA plus LAMA combination inhaler
o If already taking SAMA, discontinue and switch to SABA - 2nd line (asthmatic/steroid responsive) = LABA plus inhaled corticosteroid combination inhaler
o If patients remain breathless or have exacerbations offer triple therapy (LAMA + LABA + ICS) - Oral theophylline after trials of short and long-acting bronchodilators and those who cannot use inhaled therapy
20
Q
Features suggesting steroid responsiveness
A
previous diagnosis of asthma or atopy
a higher blood eosinophil count
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)
21
Q
Complications of COPD
A
- Osteoporosis
- Cor pulmonale
- Respiratory failure (later stages) = PaO2 <8kPa or PaCO2 >7kPa
- Pulmonary hypertension (advanced disease) fluid retention, peripheral oedema, centrally cyanosed
- Recurrent respiratory infections (H. influenzae)
22
Q
What is cystic fibrosis?
A
Autosomal recessive genetic condition affecting mucus glands
23
Q
Presentation of cystic fibrosis
A
- Neonates = Failure to thrive, Meconium ileus (bowel obstruction due to thick meconium), Rectal prolapse
- Resp = dyspnoea, Chronic cough, Thick sputum production, Recurrent respiratory tract infections
- Abdo = Steatorrhoea, Abdominal pain and distension
- Salty sweat
- Cyanosis
- Finger clubbing
- Bronchial breath sounds = harsh breath sounds equally loud on inspiration and expiration
- Bilateral coarse crackles = air passing through sputum in airways
- Dullness to percussion = lung tissue collapse/consolidation
- Nasal polyps
- Low weight or height on growth charts
24
Q
Investigations of cystic fibrosis
A
- Newborn blood spot testing
- Sweat test = High sodium and chloride conc >60mmol/L
- Genetic screening for known CFTR mutations
- Faecal elastase test = Low or no levels of elastase in CF (mucus blocking release)
- Blood: FBC, U&Es, LFT, clotting, vit ADE levels, annual glucose tolerance test
- Bacteriology = cough swab, sputum culture
- CXR = hyperinflation, bronchiectasis
- Abdo USS = fatty liver, cirrhosis, chronic pancreatitis
- Spirometry = obstructive defect
- Biochemistry = faecal fat analysis
25
Management of cystic fibrosis
- Stop smoking
- Flu vaccine
- Exercise = improves resp function and helps clear sputum
- High calorie diet and high fat intake = malabsorption and increased demand
- Fat soluble vitamin supplements (ADEK)
- CREON tablets to replace lipase
- Chest physiotherapy = postural drainage, airway clearance techniques
- Abx = acute infective exacerbations and prophylactically
o Flucloxacillin = staph. Aureus
o Amoxycillin = haemophilus influenzae
- Mucolytics (nebulised dornase alfa)
- B2 agonists (salbutamol) and inhaled corticosteroids (beclomethasone)
- Amiloride = inhibits Na+ transport less mucus
- Pancreatic enzyme replacement (CREON tablets)
- Ursodeoxycholic acid for impaired liver function
- Liver transplant (Cirrhosis)
- Treatment of CF-related diabetes
- Screening/Tx for osteoporosis = DEXA bone scanning
- Fertility and genetics counselling
- Advanced disease = oxygen, diuretics, non-invasive ventilation, lung/heart transplant
- Minimise contact with other CF patients
26
Complications of cystic fibrosis
- Recurrent infections
- Pulmonary Bronchiectasis, Pneumothorax, Respiratory failure
- Cor pulmonale
- GI pancreatic insufficiency, distal intestinal obstruction syndrome, gallstones, cirrhosis, liver failure
- Male infertility congenital bilateral absence of vas deferences
- Osteoporosis
- Arthritis
- Vasculitis
- Nasal polyps
- Sinusitis
- Hypertrophic pulmonary osteoarthropathy
- Diabetes
- Vitamin D deficiency
27
Causes of lung cancer
- Cigarette smoking (including passive)
- Occupational = Asbestos, Coal and products of coal combustion (tar), Chromium, Arsenic, Nickel, Petroleum products, Iron oxide
- Environmental = Radon exposure, Ionising radiation
- Host factors = pulmonary fibrosis, HIV infection
28
Types of lung cancer
- Small cell lung carcinoma (cigarette smoking)
o Often arises in central bronchus from endocrine cells
o Secretes polypeptide hormones
o Early development of widespread metastases
- Non-small cell lung carcinoma
o Squamous cell carcinoma (cigarette smoking)
o Tumours centrally and frequently cavitate with central necrosis
o Arise from epithelial cells associated with production of keratin
o Cause obstructive lesions of bronchus with post-obstructive infection
o Local spread common
- Adenocarcinoma (asbestos/non-smokers)
o Central or peripheral
o Usually single lesions but can arise in multifocal pattern (can be bilateral)
o Originate from mucus-secreting glandular cells
o Metastases common
- Carcinoid tumours
- Lymphomas
- Benign tumour
29
Metastases of lung cancer
liver, bone, adrenal glands, brain
30
Presentation of lung cancer
- Cough and haemoptysis
- Breathlessness
- Chest pain
- Wheeze
- Recurrent infections (pneumonia)
- Weight loss
- Metastatic disease = Bone pain, Headache, Seizures, Neurological deficit, Hepatic pain, Abdominal pain
- Finger clubbing squamous cell
- Lymphadenopathy
- Gynaecomastia adenocarcinoma
31
Investigations of lung cancer
- CXR Hilar enlargement, Consolidation, Lung collapse, Pleural effusion (unilateral)
- CT contrast of chest, abdo, pelvis for staging
- PET CT
- Bronchoscopy with endobronchial ultrasound + biopsy
- Cytology = Sputum and pleural fluid
- FBC down
32
TNM classification of lung cancer
- Tumour
o T1 <3cm
o T2 >3cm
o T3 = invades chest wall, diaphragm and pericardium
o T4 = invades mediastinum, heart, great vessels, trachea, oesophagus, vertebra, carina, malignant effusion, metastases in same lobe
- Nodes
o N0 = no nodes
o N1 = hilar nodes
o N2 = same side mediastinal nodes/subcarinal
o N3 = contralateral mediastinum/supraclavicular
- Metastasis
o M1a = tumour on same side
o M1b = tumour elsewhere
33
Management of lung cancer
- Non-small cell lobectomy, RT, chemo
- Small cell (worse prognosis) Chemotherapy and radiotherapy,
- Endobronchial treatment with stents/debulking = palliative
- Pleural drainage for symptom relief
- Medications = Analgesia, steroids, antiemetics, bronchodilators, antidepressants
- Surgery lobectomy, pneumonectomy
34
Contraindications for surgery in lung cancer
o Stage IIIb or IV
o FEV1<1.5L
o Malignant pleural effusion
o Tumour near hilum
o Vocal cord paralysis
o SVC obstruction
35
Complications of lung cancer
- Recurrent laryngeal nerve palsy (hoarse voice)
- Phrenic nerve palsy (shortness of breath)
- Superior vena cava obstruction (facial swelling, difficulty breathing, distended veins in neck and upper chest)
- Horner’s syndrome
- Syndrome of inappropriate ADH (hyponatraemia)
- Cushing’s syndrome
- Hypercalcaemia
- Limbic encephalitis
- Lambert-Eaton myasthenic syndrome
36
Other cancers that metastasise to lung
Breast, Colorectal, Renal cell, Bladder, Prostate
37
Classification of pneumonia
- Community-acquired pneumonia (CAP) Occurs across all ages but commoner in extremes of age
- Hospital-acquired pneumonia (HAP) Patients >48 hrs of initial admission or healthcare setting within last 3 months
o Mostly elderly, ventilator-associated and post-operative
38
Risk factors for pneumonia
- Co-morbidities = HIV, DM, CF, COPD, bronchiectasis
- Smoking
- Excess alcohol
- IVDU
- Immunosuppressant therapy
39
Risk factors for aspiration pneumonia
o Poor dental hygiene
o Swallowing difficulties
o Prolonged hospitalisation or surgical procedures
o Impaired consciousness
o Impaired mucociliary clearance
40
Causes of pneumonia
- Streptococcus pneumoniae
- Haemophilus influenzae
- Klebsiella pneumoniae alcoholics
- Atypical pneumonia Legionella pneumophila, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Coxiella burnetiid (Q fever), Chlamydia psittaci
- Aspiration pneumonia = after inhaling foreign material
41
Presentation of pneumonia
- Dyspnoea = alveoli filled with pus and debris
- Dry or productive cough
- Fever + rigors
- Haemoptysis
- Pleuritic chest pain
- Systemic: Night sweats, Malaise, Anorexia
- Raised RR, raised HR, low BP
- Coarse crackles = consolidation of lung parenchyma
- Dull to percussion
- Decreased air entry
- Bronchial breath sounds
- Purulent sputum
- Cyanosis
- Confusion
42
Severity of pneumonia
- C – confusion
- U – urea >7
- R – resp rate >/=30
- B – blood pressure <90/60mmHg
- 65 – age >/= 65
- Score of 0 treatment at home
- Score of 1 or 2 consider hospital assessment
- Score of 3 or 4 urgent admission to hospital
43
CXR in pneumonia
o ‘Air bronchogram’ in consolidated area = black branch
o Multi-lobar = S.pneumoniae, S.aureus, Legionella spp.
o Multiple abscesses = S. aureus
o Upper lobe cavity = Klebsiella pneumoniae
44
Management of pneumonia
- 1st line Abx if mild = Amoxicillin 5-7 days
o IV antibiotics if severe = Co-amoxiclav or clarithromycin 7-10 days
o First dose antibiotics administered within 4 hours of presentation in hospital
- Maintain O2 sats between 94-98%
- Analgesia = paracetamol or NSAIDs
- Repeat CXR at 6 wks
45
Prevention of pneumonia
- Polysaccharide pneumococcal vaccine
- Influenza vaccine for >65 y/o, immunocompromised or with medical co-morbidities
- Smoking cessation
46
Complications of pneumonia
- Respiratory failure
- Pleural effusion and empyema
- Lung abscess
- Sepsis
47
Risk factors for pulmonary embolism
- Immobility
- Recent surgery
- Long haul flights
- Pregnancy
- Hormone therapy with oestrogen
- Malignancy
- Smoking
- Obesity
- Polycythaemia
- SLE
- Thrombophilia
48
Causes of PE
- Clots from pelvic and abdominal veins or femoral DVT
- Right ventricular thrombus (post-MI)
- Septic/ fat/ air/ amniotic fluids emboli
- Neoplastic cells
- Parasites
- Foreign material = IVDU
49
Presentation of PE
- Sudden onset unexplained dyspnoea
- Pleuritic chest pain
- Dizziness
- Cough with/without blood
- Past Hx or FHx of thromboembolism
- Fever
- Cyanosis (hypoxia)
- Tachypnoea
- Tachycardia
- Hypotension
- Raised jugular venous pressure
- Pleural rub
- Pleural effusion
50
Investigations of PE
- CT pulmonary angiography (GS)
o Saddle PE straddles bifurcation of pulmonary trunk
- CXR often normal or Decreased vascular markings, Blunting of costophrenic angle, Wedge-shaped areas of infarction, Pulmonary oligaemia
- ECG (may be normal) May show sinus tachycardia, Right atrial dilation with tall peaked P waves in lead II, RBBB, Right ventricular strain
- ABG (may be normal) = arterial hypoxaemia
- Plasma D-dimer = not diagnostic but negative rules out PE
- Ultrasound doppler = Leg and pelvis looking for clots
51
Wells score
- Active cancer
- Paralysis, paresis or recent plaster immobilisation of leg
- Recently bedridden for >3d or major surgery in last 12wks
- Local tenderness along distribution of deep venous system
- Entire leg swollen
- Calf swelling >3cm compared with other leg
- Pitting oedema
- Collateral superficial veins
- Previously document DVT
52
Management of PE
- Admit based on PESI score
- 1st line = therapeutic anticoagulation (apixaban)
o 3m if provoked
o 6m if unprovoked or if active cancer
- 2nd line = Low molecular weight heparin (enoxaparin)
- High flow oxygen = All patients unless significant chronic lung disease
- IV fluids and inotropic agents = Improve pumping of right heart
- Thrombolysis for massive PE = Improve pulmonary perfusion quicker than anticoagulation
- Surgical embolectomy
53
What is bronchiectasis?
Chronic infection of bronchi and bronchioles leading to permanent dilation and thinning of these airways
54
Causes of bronchiectasis
- H. influenzae
- Strep. Pneumoniae
- Staph. Aureus
- Pseudomonas aeruginosa
- Congenital CF, young’s syndrome, primary ciliary dyskinesia, Kartagener’s syndrome
- Post infection measles, pertussis, bronchiolitis, pneumonia, TB, HIV, whooping cough
- Other bronchial obstruction, allergic bronchopulmonary aspergillosis, hypogammaglobulinaemia, rheumatoid arthritis, UC
- Idiopathic
55
Presentation of bronchiectasis
- Persistent productive cough
- Copious foul-smelling purulent sputum
- Intermittent haemoptysis
- Chest pain
- Dyspnoea
- Finger clubbing
- Coarse inspiratory crepitations
- Wheeze
56
Investigations of bronchiectasis
- CXR dilated bronchi with thickened walls, multiple cysts containing fluid, tramline opacities and ring shadows
- HRCT chest Thickened, dilated bronchi with cysts at end of bronchioles, Airways larger than associated blood vessels
- Spirometry obstructive pattern, assess reversibility
- Bronchoscopy locate haemoptysis, exclude obstruction and obtain culture samples
57
Management of bronchiectasis
- Airway clearance techniques and mucolytics
o Chest physiotherapy
o Flutter valve
o Aid sputum expectoration and mucus drainage
- Abx
o Pseudomonas = oral ciprofloxacin
o Haemophilus influenzae = oral amoxicillin
o Staph. Aureus = flucloxacillin
- Bronchodilators = nebulised salbutamol
- Corticosteroids (prednisolone) and itraconazole for ABPA
- Anti-inflammatory agents (Long term azithromycin) = reduce exacerbation frequency
- Surgery = localised disease or control severe haemoptysis
58
Complications of bronchiectasis
- Pneumonia
- Pleural effusion
- Pneumothorax
- Cerebral abscess
- Amyloidosis
59
What is pulmonary fibrosis?
Inflammation and replacement of normal elastic and functional lung tissue with scar tissue that is stiff and doesn’t function effectively
60
Risk factors of pulmonary fibrosis
- Occupational exposure to metals and wood dusts
- Cigarette smoking
- Infectious agents = CMV, Hep C, EBV
- Chronic gastro-oesophageal reflux disease (GORD)
- Genetic predisposition
61
Causes of pulmonary fibrosis
Lower zones
- Idiopathic
- Connective tissue disorders (SLE)
- Drug induced: amiodarone, bleomycin, methotrexate
- Asbestosis
Upper zones (CHARTS)
- Coal worker’s pneumoconiosis/ progressive massive fibrosis
- Hypersensitivity pneumonitis + Histiocytosis
- Ankylosing spondylitis
- Radiation-induced
- Tuberculosis
- Silicosis + Sarcoidosis
62
Presentation of pulmonary fibrosis
- Dry cough
- Progressive exertional dyspnoea
- Malaise
- Weight loss
- Arthralgia (joint pain)
- Cyanosis
- Finger clubbing
- Bi-basal fine end-inspiratory crackles
- Symmetrical reduced chest expansion
63
CT of pulmonary fibrosis
o Basal distribution = abnormalities more pronounced at bases
o Subpleural reticulation
o Traction bronchiectasis
o Honeycombing/ ground glass appearance
64
Management of pulmonary fibrosis
- Pulmonary rehabilitation
- Remove/treat underlying cause
- Home oxygen if hypoxic at rest
- Stop smoking
- Physiotherapy and pulmonary rehabilitation
- Pneumococcal and flu vaccine
- Palliative care/advanced care planning
- Lung transplant
- Pirfeniodone = antifibrotic and anti-inflammatory
- Nintedanib = monoclonal antibody targeting tyrosine kinase
65
Presentation of sarcoidosis
- Fever
- Weight loss
- Fatigue
- Dry cough
- Progressive dyspnoea
- Reduced exercise tolerance
- Chest pain
- Red lumps form on shins, (thighs and forearms) = erythema nodusum
o With/out polyarthralgia = aches in joints and joint pain
- Bilateral hilar lymphadenopathy
- Hepatomegaly and Splenomegaly
- Conjunctivitis
- Glaucoma
- Anterior uveitis
- Enlargement of lacrimal and parotid glands
- Bell’s palsy = lesion of facial nerve (CN7)
- Facial numbness, dysphagia, visual field defects
- Lupus pernio = blueish-red/purple nodules and plaques over nose, cheek and ears
- Renal stones
- Cardiac arrhythmias
66
Gold standard investigation for sarcoidosis
Bronchoscopy with Tissue biopsy = Non-caseating granulomata with epithelioid cells
67
Blood results in sarcoidosis
o Hypercalcaemia
o Raised Serum ACE
o Raised ESR/CRP
o Raised serum soluble interleukin-2 receptor
o Raised immunoglobulins
o Lymphopenia
o Raised LFT (liver involvement)
68
Management of sarcoidosis
- Asymptomatic/mild Sx = no treatment
- 1st line = oral corticosteroids (prednisolone) for 6-24 months with bisphosphonates
- 2nd line = methotrexate or azathioprine
69
Complications of sarcoidosis
- Lungs mediastinal lymphadenopathy, pulmonary fibrosis, pulmonary nodules
- Liver liver nodules, cirrhosis, cholestasis
- Eyes uveitis, conjunctivitis, optic neuritis
- Skin erythema nodosum, lupus pernio, granulomas
- Heart BBB, heart block, myocardial muscle involvement
- Kidneys kidneys stones, nephrocalcinosis, interstitial nephritis
- CNS nodules, pituitary (DI), encephalopathy
- PNS facial nerve palsy, mononeuritis multiplex
- Bones arthralgia, arthritis, myopathy
70
Risk factors for a pleural effusion
- Previous lung damage
- Asbestos exposure
71
Classification of pleural effusion
Exudative = high protein count (>30g/L)
Transudative = low protein count (<30g/L)
72
Exudative causes of pleural effusion
Lung cancer/mets
Pneumonia
Tuberculosis
Subphrenic abscess
Rheumatoid arthritis
SLE
Pancreatitis
PE
Dressler’s syndrome
Yellow nail syndrome
73
Transudative causes
Congestive cardiac failure
Hypoalbuminemia liver disease, nephrotic syndrome, malabsorption
Hypothyroidism
Meig’s syndrome (R side pleural effusion with ovarian malignancy)
Constrictive pericarditis
74
Cause of recurrent pleural effusions
Malignant mesothelioma
75
Presentation of pleural effusion
- Shortness of breath especially on exertion
- Pleuritic chest pain
- Non-productive cough
- Loss of weight = malignancy
- Reduced chest expansion
- Trachea may be deviated away from large effusion
o If associated lung collapse, trachea will deviate towards lesion
- Stony dull percussion over effusion
- Diminished breath sounds
- Deviated apex beat
- Decreased tactile vocal fremitus
- Loss of vocal resonance
76
CXR in pleural effusion
o Small effusions reduce/blunt costophrenic angles
o Fluid in lung fissures
o Larger ones seen as water-dense shadows with concave upper borders where it meets chest wall and mediastinum
o Completely flat horizontal upper border = pneumothorax
o Tracheal and mediastinal deviation (massive effusion)
77
Diagnostic test for pleural effusion
Aspiration/thoracentesis/pleural tap
o Purulent in empyema = pus effusion
o Turbid (cloudy/opaque) in infected effusion
o Milky in chylothorax = lymph fluid effusion
o Protein count, cell count, pH, glucose, LDH and microbiology
78
Management of pleural effusion
- Small effusions = Conservative management as likely to resolve
- Large effusions
o Pleural aspiration = relieve pressure but effusion may recur
o Chest drain = drain effusion and prevent recurring
- Indwelling pleural catheter
- Opioids to relieve dyspnoea
- Surgery = Persistent collections and increasing pleural thickness
- Infected pleural effusion (empyema) = chest drain and Abx
79
What is a pneumothorax?
Air in pleural space separating lung from chest wall and can lead to partial/complete collapse of lung
80
What is a tension pneumothorax?
Trauma to chest wall the creates one-way valve that lets air in but not out of pleural space
81
Presentation of pneumothorax
- Sudden onset of dyspnoea
- Unilateral pleuritic chest pain
- Reduced expansion
- Hyper-resonance to percussion
- Diminished breath sounds of affected lung
- Tracheal deviation away from side of tension pneumothorax
- Tachycardia
- Hypotension
82
Investigations of pneumothorax
- CXR = Area devoid of lung marking, peripheral to edge of collapsed lung
- ABG = hypoxia
- CT thorax = small pneumothorax
83
Management of pneumothorax
Primary pneumothorax
o No SoB and <2cm rim of air = discharge with outpatient CXR
o If SoB and/or >2cm air = aspiration and reassessment
o If aspiration fails twice = chest drain inserted
Secondary pneumothorax
o Patient >50 and rim of air >2cm and/or SOB = chest drain
o Rim of air 1-2cm = aspiration
o If aspiration fails = chest drain
o If <1cm = oxygen and admit
o All patients admitted for min 24 hrs
Iatrogenic pneumothorax
o Majority resolve with observation
o If Tx required, then use aspiration
o Ventilated patients need chest drains and some with COPD
Persistent/recurrent pneumothorax
o Video-assisted thoracoscopic surgery (VATS)
Tension pneumothorax
o Needle decompression into 2nd intercostal space in midclavicular line
o Chest drain inserted in triangle of safety
84
Discharge advice after a pneumothorax
- Smoking cessation
- Absolute contraindication for fitness to fly. Can travel 2 weeks after successful drainage or 1 week post check XR
- Scuba diving = permanently avoided unless patient undergone bilateral surgical pleurectomy + normal lung function + chest CT postoperatively
85
Causes of pulmonary hypertension
- Group 1 = primary pulmonary hypertension or connective tissue disease (SLE)
- Group 2 = L HF due to MI or systemic HTN
- Group 3 = chronic lung disease (COPD)
- Group 4 = pulmonary vascular disease (PE)
- Group 5 = miscellaneous (Sarcoidosis, glycogen storage disease and haematological disorders)
86
Presentation of pulmonary hypertension
- Shortness of breath
- Syncope
- Chest pain
- Lethargy/fatigue
- Tachycardia
- Raised JVP
- Hepatomegaly
- Loud pulmonary second sound
- Right parasternal heave
- Peripheral oedema
87
Investigations of pulmonary hypertension
- CXR = dilated pulmonary artery, RV hypertrophy
- ECG = RV hypertrophy, right axis deviation, R BBB
- Echocardiogram = estimate pulmonary artery pressure
- Raised NT-proBNF = RV failure
- LFTs = Portal hypertension
- Autoimmune screening
88
Management of pulmonary hypertension
- Treat underlying cause
- Oral CCBs = pulmonary vasodilators
- IV prostanoids (epoprostenol)
- Endothelin receptor antagonists (macitentan)
- Phosphodiesterase-5 inhibitors (sildenafil)
- Supportive Tx for complications
89
Complications of pulmonary hypertension
- Respiratory failure
- Arrythmias
- Heart failure
90
Risk factors for obstructive sleep apnoea
- Middle age
- Male
- Obesity
- Alcohol
- Smoking
- Macroglossia: acromegaly, hypothyroidism, amyloidosis
- Large tonsils
- Marfan’s syndrome
91
Presentation of obstructive sleep apnoea
- Excessive snoring
- Periods of apnoea during sleep (reported by partner)
- Daytime sleepiness
- Morning headache
- Waking up unrefreshed from sleep
- Concentration problems
- Reduced oxygen saturation during sleep
- Compensated respiratory acidosis
- Severe cases Hypertension, heart failure, myocardial infarction, stroke
92
Investigations of obstructive sleep apnoea
- Epworth Sleepiness Scale
- Multiple Sleep Latency Test
- Sleep studies (polysomngraphy)
93
Management of obstructive sleep apnoea
- Reversible risk factors Weight loss, reduced alcohol, smoking cessation
- CPAP to maintain airway patency
- Intra-oral devices (mandibular advancement)
- Surgery uvulopalatopharyngoplasty
- Inform DVLA if causing excessive daytime sleepiness
94
Risk factors for a lung abscess
- Aspiration pneumonia
o Poor dental hygiene
o Previous stroke
o Reduced consciousness
- Haematogenous spread
o Infective endocarditis
- Direct extension
o Empyema
- Bronchial obstruction
o Lung tumour
95
Presentation of lung abscess
- Sx develop over weeks
- Night sweats
- Weight loss
- Fever
- Productive cough
- Foul-smelling sputum
- Haemoptysis
- Chest pain
- Dyspnoea
- Dull percussion and bronchial breathing
- Clubbing
96
Investigations for lung abscess
- CXR
o Fluid-filled space within area of consolidation
o Air-fluid level
- Sputum and blood cultures
97
Management of lung abscess
- IV Abx
- Percutaneous drainage
- Surgical resection
98
Causes of respiratory alkalosis
- Anxiety leading to hyperventilation
- Pulmonary embolism
- Salicylate poisoning
- CNS disorders: stroke, SAH, encephalitis
- Altitude
- Pregnancy
Finals
flashcards
Decks in class (23)
# Cards
-
Breast33
-
Cardiology120
-
Dermatology93
-
Emergency Medicine89
-
Endocrinology88
-
ENT117
-
Gastroenterology107
-
Geriatrics and palliative care74
-
Haematology86
-
Neurology133
-
Obstetrics201
-
Gynaecology149
-
Ophthalmology112
-
Paediatrics202
-
Renal143
-
Respiratory98
-
Sexual health109
-
Liver53
-
Infectious diseases87
-
Rheumatology104
-
Orthopaedics79
-
General Surgery101
-
Psychiatry171
