Causes of interstitial lung disease (8)
- Idiopathic pulmonary fibrosis
- Rheumatological diseases - systemic sclerosis, rheumatoid arthritis, Psoriatic arthritis, ank spon, poly/dermatomyositis
- Eosinophilic - Aspergillosis
- Sarcoid
- Inhaled agents - asbestosis, silicosis
- Drugs - nitrofurantoin, MTX, bleomycin, amiodarone
- Radiation fibrosis
- TB
What are the respiratory causes of clubbing?
Interstitial lung disease CF bronchiectasis Lung Ca TB
UIP vs non-UIP CT pattern
UIP - honeycombing, traction bronchiectasis, basal predominance, subpleural involvement
Non UIP - upper and middle lung predominance, extensive ground glass, peribronchovascular predominance
Apical vs Basal distribution of fibrosis
- Apical - occupational (except asbestosis), sarcoid, psoriatic/ank spon, radiation, allergic bronchopulmonary aspergillosis
- Basal - IPF, rheumatological conditions (except psoriatic and ank spon), connective tissues, drugs, asbestosis
What are the main differences between limited and diffuse systemic sclerosis
Diffuse - skin involvement is more widespread involving more of the arms, face, trunk. Get early organ involvement with fibrosis of lungs, renal, GIT and heart
Limited - skin involvement is only extremities and/or face, more likely to have CREST syndrome, late development of pulmonary hypertension
What are the antibodies in Systemic sclerosis?
Anti-centromere (limited), Anti Scl70 (diffuse), anti RNP I, II and III (diffuse)
What is the GIT involvement in systemic sclerosis ?
oesophageal dysmotility and reflux, primary biliary sclerosis, intestinal hypomotility, colonic diverticulae
What is the renal involvement in systemic sclerosis?
Hypertensive crisis, glomerulonephritis, renal crisis
What are the causes of bronchiectasis?
- Congenital causes such as CF, primary ciliary dyskinesia, yellow nail syndrome (nail dystrophy, lymphedema, pleural effusions), Young syndrome (azoospermia, recurrent sinopulmonary infections)
- Infections - typical and atypical mycobacterial infections (incl TB), childhood pertussis
- Bronchial obstruction - foreign body, tumour, chronic aspiration, COPD
- Inflammatory/autoimmune/connective tissue disease - sarcoid, RA, Sjogrens, Marfans, UC/Crohn’s
- Immune deficiency
- Fibrosis - long standing pulmonary fibrosis
- Allergic bronchopulmonary aspergillosis .
What is bronchiectasis?
Irreversible, pathologic dilatation of the bronchi or bronchioles from an infectious process in the context of impaired drainage, chronic obstruction or abnormal antimicrobial defenses
Clinical findings in bronchiectasis
Clubbing
excessively curved, thickened yellow nails (yellow nail syndrome)
Coarse creps
Moist productive cough
Widespread expiratory wheeze
Look for pulmonary hypertension
Nasal polyps in CF
Lymph nodes if there is carcinoma of the lung
Look for the position of the apex beat - dextrocardia in Kartagener’s syndrome
Cor pulmonale/signs of right heart failure
What do you see on CT chest in bronchiectasis ?
Dilation of bronchi
Tram tracking
Signet ring sign (bronchial diameter greater than adjacent vessel
Clinical signs in pneumonectomy
- Tracheal deviation to side of pneumonectomy
- Chest wall flattening on side of pneumonectomy
- Decreased chest expansion on side of pneumonectomy
- Absent breath sounds
- Pneumonectomy scar
- Dull percussion note
Indications for a lobectomy
Bronchiectasis Malignancy/solitary pulmonary nodule CF Lung abscess TB
Indications for a pneumonectomy
Bronchiectasis
Malignancy
TB
CXR in lobectomy
Tented/raised hemidiaphragm
Loss of volume in one hemithorax
Potentially deviated trachea
Pleural effusion clinical signs
trachea may be displaced away from effusion
Reduced chest expansion on that side
Percussion - stony dull
Reduced breath sounds
Area of bronchial breathing just above the effusion
Reduced vocal resonance
Light’s criteria in pleural effusion
Pleural fluid protein to serum protein > 0.5
Pleural fluid LDH to serum LDH > 0.6
Total pleural fluid LDH > 2/3 upper limit of normal
Pleural effusion causes
Exudate - infective, malignancy, inflammatory like in RA/SLE etc, pulmonary infarction, drugs, sarcoid, asbestosis, oesophageal rupture
Transudate - CCF, hepatic hydrothorax, hypoalbuminaemia, nephrotic syndrome, Constrictive pericarditis, peritoneal dialysis
What is yellow nail syndrome associated with?
Bronchiectasis
What pattern is seen on PFTs for bronchiectasis
Can be restrictive or obstructive - obstructive more common
What is the classic sign seen on CT chest in bronchiectasis
Signet ring sign - when the diameter of the bronchial diameter is greater than the adjacent vessel diameter
