What are causes of upper lobe fibrosis?
CHARTS
- Coal worker’s penumoconiosis
- Histocytosis
- Ankylosing Spondylitis
- Radiation
- TB
- Sarcoidosis/Silicosis
What is extrinsic allergic alveolitis?
EAA, aka, hypersensitivity pneumonitis, is a condition caused by hypersensitivity induced lung damage due to a variety of inhaled organic particles.
It is thought to be due to immune complexes (type III) and Type IV hypersensitivity.
What are common causes of Extrinsic allergic alveolitis?
- Bird fanciers’ lung (avian proteins)
- Farmer’s lung: spores form mouldy hay
- Malt workers: from fungal spored
How does extrinsic allergic alveolitis present?
Clinical Features
- Acute (4-8 hours after exposure)
- Fever, chills, malaise, headache
- Cough
- Dyspnoea without wheezing
- Symptoms subside after 12 hours/several days
- Fine crackles
- Chronic (months after continuous exposure)
- Insidious onset of fatigue
- Productive cough
- Progressive dyspnoea
- Bilateral crackles
- Weight loss (due to increased respiratory effort)
Which diagnosis do you need to consider in a young person presenting with COPD symptoms?
Aopha-1-antitrypsin deficiency.
Here, there is a protease inhibtor deficiency in the liver, leading to the A1AT not being released from the liver.
A1AT is required to protect the lung from neutrophil elastase; without it, emphysema occurs.
What are the investigations for alpha-1-antitrypsin deficiency?
- A1AT concentrations
- Spirometry: obstructive picture
Summarise the managmetn of A1AT deficiency.
Conservative:
- Never smoke
- Physiotherapy
Medical:
- Bronchodilators
- IV A1AT protein concentrates
Surgical:
- Lung volume reduction surgery
- Lung transplantation
What is the managment of obstructive sleep apnoea?
- Weight loss
- CPAP is first-line for moderate-sever OSA
- Intra-oral devices (e.g. madibular advancement) if CPAP not tolerated or only very mild OSA
What are the causes of a mediastinal mass?
The commonest causes of an anterior mediastinum mass are:
- Teratoma
- Terrible lymphadenopathy
- Thymic mass
- Thyroid mass
How can the causes for pleural effusion be subclassified?
Give causes for each class.
Transudate (< 30g/L of protein):
- Heart failure
- Hypoalbuminaemia (lider disease, nephrotic syndrome, malabsorption)
- Meig’s syndrome (benign ovarian tumour, ascites, pleural effusion)
- Hypothyroidism
Exudate (>30g/L of protein):
- Infection: pneumonia, TB, subphrenic abscess
- Connective tissue diseases: RA, SLE
- Malignancy: lung cancer, mesothelioma
- Pancreatitis
What are the NICE guidelines for smoking cessation?
Offer nicotine replacement therapy plus varenicline or burpopion. Try this for 2-4 weeks then reevaluate. Only give further prescriptions to patients who demonstrate they are still trying to quit.
What are the side effects of nicotine replacement therapy?
Adverse effects include nausea & vomiting, headaches and flu-like symptoms.
NICE recommend offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past
What is Varenicline?
What are the contraindications?
Varenicline is a nicotinic receptor partial agonist.
Adverse effects include nausea, headache, insomnia.
Contraindications:
- Use with caution in patients with a history of depression/self-harm
- Contraindicated in pregnancy and breast feeding
What is bupropion?
What are the contraindications?
Bupropion is a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist.
Contraindications:
- As there is a small risk of seizures, it is contraindicated in epilepsy
- Also not used in pregnancy
Summarise the investigations and diagnosis of COPD.
COPD should be considered in patients >35 who are (ex-)smokersand have symptoms such as exertional breathlessness, cough, regular sputum production.
The following investigations are recommended:
- Post-bronchodilator spirometry: demonstrating obstruction: FEV1/FVC raion < 70%
- Chest X-ray: hyperinflation ± flattened hemidiaphragm, bullae, exclude lung cancer
- FBC: 2° polycythaemia
PEFR is of limited use in COPD.
How is severity of COPD classified?
Using the GOLD Classification. This incorporates the mMRCA dyspnoea score, airflow limitation, and the number of exacerbations every year. It divides patients into groups A-D.
Airflow limitation:
Using spirmetry: all patients have obstruction (FEV1/FVC < 70%) plus:
- 1: FEV1 >80% (of predicted)
- 2: FEV1 50-79% (of predicted)
- 3: FEV1 30-49% (of predicted)
- 4: FEV1 < 30% (of predicted)
mMRC scale:
- SOB on vigurous exertion
- SOB on hurrying or walking up stairs
- Walks slowly/has to stop for breath
- Stops for breasth after <100m/few min
- Too breathless to leave the house
Exacerbations:
- 0-1
- ≥2
How can the cause of pulmonary effusion be investigated?
BTS recommends:
- Imaging:
- PA CXR
- CXR: especially for aspiration
- Contrast CT - can help with underlying diagnosis, particularly exudative
- Aspiration. Send fluid for:
- pH
- Lactate dehydrogenase
- Protein
- Cytology and microbiology
How can you determine whether a pleural effusion is transudate or exudate?
Protein content of aspiration:
- >30 g/L -> Exudate
- < 30 g/L -> Transudate
If the protein level is between 25-35 g/L, Light’s criteria should be applied. Exudate if:
- Pleural protein/serum protein >0.5
- Pelural fluid LDH/serum LDH >0.6
- Pleural fluid LDH >2/3rds ULN of serum LDH
What is the management of recurretn pleural effusions?
- Recurrent aspirations
- Pleurodesis (fusing visceral and parietal pleura)
- Indwelling pleural catheter
- Drug management to alleviate symptoms )e.g. opioids to alleviate dyspnoea)
What are the parameters of the CURB65?
Confusion
Urea >7.0 mmol/L
Resp Rate >30
BP <90 systolic, <60 diastolic
65 or older
What lung cancer is most common in non-smokers?
Adenocarcinoma.
Associated features are Hypertrophic pulmonary osteoartropathy (triad of periostitis, digital clubbing and painful arthropathy of the large joints) and gynaecomastia.
What are the features of small cell lung cancer, squamous cell and adenocarcinoma?
Small cell:
- LEMS
- ADH -> SIADH
- (Atypical: excess ACTH -> HTN, hyperglycaemia, hypokalaemia)
Squamous cell:
- PTHrp -> Hypercalcaemia
- Clubbing
- HPOA (triad of periostitis, digital clubbing and painful arthropathy of the large joints)
- Ectopic TSH
Adenocarcinoma:
- Gynaecomastia
- HPOA (triad of periostitis, digital clubbing and painful arthropathy of the large joints)
What does this CXR show?
This is a RUL consolidation - hints are that you can still see both
When would you consider NIV in a patient with an IECOPD?
NIV should be considered in all patients with an acute exacerbation of COPD in whom a respiratory acidosis (PaCO2>6kPa, pH <7.35 ≥7.26) persists despite immediate maximum standard medical treatment.
