Cryptogenic organising pneumonia
- Diffuse interstitial lung disease
- M = F; presents in 5th-6th decade
- No association with smoking
- Symptoms: fever, malaise, cough, SOB
- No response to antibiotics
- Bloods: leukocytosis, high ESR / CRP
- Imaging: bilateral patchy, diffuse consolidative, ground glass opacities
- Lung function tests restrictive (but sometimes obstructive / normal)
- Reduced transfer factor
- Mx: sometimes steroids
Yellow nail syndrome
- yellow, clubbed nails
- bronchiectasis
- pleural effusions
- congenital lymphoedema
- recurrent sinusitis
Lung cancer surgery indications and contraindiactions
Indications
- stage 1 or 2 disease
- FEV1 > 60% predicted
Contraindications
- FEV1 < 1.5 litres (lobectomy)
- FEV1 < 2L (pneumonectomy)
- malignant pleural effusion
- tumour near hilum
- vocal cord paralysis
- SVC obstruction
Non-small cell lung cancer types
Squamous cell: central, PTHrP secretion
Adenocarcinoma: non-smokers, peripheral
Large cell: aggressive, BhCG secretion
Non-small cell lung ca mx
1) Surgery: stage 1-2
2) Curative / palliative radiotherapy
Poor response to chemotherapy
Pneumonia cause in cases associated with cold sores
Strep pneumoniae
Cavitating pneumonia associated with alcoholics
Klebsiella
Bug that can cause IECOPD
Haemophilus influenzae
Post influenza pneumonia bug
S Aureus
How to assess suitability for lung cancer surgery
- combined PET / CT gives an idea on LN involvement
- FEV1 < 1.5 litres is considered a general cut-off point for lobectomy ( <2L for pneumonectomy)
Other general contraindications
- malignant pleural effusion
- tumour near hilum
- vocal cord paralysis
- SVC obstruction
Best long-term intervention for sleep apnoea
Weight loss (CPAP may be needed in the interim as well)
Small cell lung cancer paraneoplastic syndromes
- SIADH
- ACTH secretion
- Lambert-Eaton
Squamous cell carcinoma paraneoplastic syndromes
- PTHrP
- clubbing
- hypertrophic pulmonary osteoarthropathy
- ectopic TSH -> hyperthyroidism
Adenocarcinoma paraneoplastic syndromes
- gynaecomastia
- hypertrophic pulmonary osteoarthropathy
Chronic asthma treatment ladder
1) SABA
2) SABA + low dose ICS
3) SABA + low dose ICS + montelukast
4) SABA + low dose ICS + LABA (+/- montelukast if it had any effect)
5) SABA (+/- montelukast) & maintenance and reliever LABA/ICS combo
6) Increase steroid dose
7) Increase steroid dose further OR add LAMA OR theophylline
FVC threshold for ventilatory support in neuromuscular disease
20ml/kg
Chronic COPD treatment ladder
1) SABA / SAMA
2) LABA + ICS (if asthmatic features)
OR LABA + LAMA (if no asthmatic features)
3) LABA + LAMA + ICS
4) Roflumilast (>2 exacerbations in a year, despite triple inhaled therapy, where FEV1 is less than 50% of predicted)
Others
- oral theophylline
- mucolytics
- lung volume reduction surgery
Secondary pneumothorax management
Definition: significant respiratory co-morbidity OR over 50 and smoker
<1cm: oxygen, admit for observation
1-2cm and asymptomatic: aspiration -> chest drain if residual >1cm
> 2cm or symptomatic: chest drain
Primary pneumothorax management
<2cm and asymptomatic: consider discharge
> 2cm or symptomatic: aspiration -> chest drain if residual >2cm
Pneumocystis pneumonia prophylaxis
Co-trimoxazole OR nebulised pentamidine
Management of severe pneumocystis pneumonia
IV clindamycin & primaquine
OR
IV pentamidine
AND prednisolone (if PO2 <9.3)
Symptoms of extrinsic allergic alveolitis
E.g. bird fancier’s lung, farmer’s lung, malt worker’s lung
Acute: 4-8 hrs after exposure, SOB, dry cough, fever
Chronic: fibrosis (upper lobe predominant)
Pulmonary alveolar proteinosis
- Rare diffuse lung disease where alveolar sacs become filled with protein rich fluid
- primary or secondary e.g. PCP / atypical mycobacteria as cause
- fluid typically stains for PAS
- ages 20-60
- crazy paving pattern on CT
- spirometry: restrictive, reduced TLC, reduced KCO
- mx: washing alveoli with saline during bronchoscopy
Bronchial carcinoid
- flushing etc and diarrhoea when hepatic mets occur (carcinoid syndrome)
- symptoms unrelated to smoking
- ix: imaging and 5-IHAA
- mx: surgery if no mets
