Respiratory

AsthmaBronchiectasisConsolidationCOPDCor Pulmonale and Pleural RubCystic FibrosisFibrosing AlveolitisLung CancerOld TBPickwickian SyndromePleural EffusionPneumothorax

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Asthma

Chronic asthma

WheezeCoughSOB

Diagnosis

PEFR >25% variablePEFR + FEV1 inc post nebDec FEV1Dec FEV1/ FVC ratio

(<70%)Gas trapping

Triggers

InfectionEmotionExerciseDrugs

Management of chronic asthma

Step 1. Occasional short actingStep 2. Short acting and steroidStep 3. Short acting + increase steroid or short

acting + add long acting beta2Step 4. Add other alternativesStep 5. Add oral steroid

Acute asthma

SevereH R >110A BG pO2 <8R R >25P EFR <50%

Life threateningPEFR <33%ExhaustionBradycardia/ hypotension

Wheeze differential

COPDLVFPANTumourEosinophilic lung disease

Extrinsic asthma (kids)

(Dermatophagoides pteronyssinus)

Intrinsic asthma (late onset)

Smoking related – more severe and continuous

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Bronchiectasis (= chronic necrotising infection)

Clubbing

Types (Reid’s classification)

1. Cylindrical2. Varicose3. Cystic/ saccular

Tests:CXR/ HRCT/ sputum cultureAetiology testing

Causes

Congenital Post-infective OtherCF TB/ HIV SarcoidKartagener’s Measles AspirationYoung’s Pertussis Hypogammaglob Pneumonia Idiopathic ABPA

Management

P hysioA ntibioticsB ronchodilatorS urgery – if restricted to a single lobe

Haemoptysis

Complications

SinusitisHaemoptysisBrain abscessAmyloidosisEffusionPneumothoraxPneumonia

Bilateral coarse and end insp crackles – coarse bronchiectasis. They clear with coughing

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Consolidation

Dec movement of affected sideBronchial BS (bronchial)Crackles ( )Dec PN – not stony dull (THUD)

Causes of pneumonia

Community Hospital

Typical AtypicalS. pneumo Chlamydia pneumoH. influenzae Mycoplasma pneumo Legionella pneumo Chlamydia psittacii

Poor prognosis signs

Confusion and comorbiditiesUrea >7RR >30BP Sys <90/ Dias <60Age >65

Causes of recurrent pneumonia

AspirationAntibioticsCancerChurg–Strauss

CNS/ PNS problems

DIC

Pericarditis/ myocarditis

HepatitisHaemolytic anaemia

Glomerulonephritis

Extrapulmonary manifestations of mycoplasma

Pulmonary eosinophilic disorders

Löffler’sABPAChronic pulmonary eosinophilia

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COPD (3 months cough/ year for 2+ years

– a combination of chronic bronchitis and emphysema)

Hyperresonant (and loss of cardiac dullness)Decreased cricothyroid distanceDecreased air entry

Classification

Mild FEV1 60–80%Mod FEV1 40–60%Sev FEV1 <40%

Treatment

Nebulisers/ inhalers/ O2/ antibiotics

Other treatments

Nutrition (diet high in n-3 fatty acids)Bullectomy: COPD with >1/3 of hemithorax

taken upLung transplantation: <60 yrs with no

underlying systemic probs or cancerLung volume reduction surgery

Cricosternal distance <3 finger breadths

Genetics in COPD

1. Alpha1 antitrypsin deficiency2. TNF-alpha3. Microsomal epoxide hydroxylase

BOOM

Long term O2 therapy

pO2 on air <7.3pO2 7.3–8 with portal hypertension/ peripheral

oedema/ nocturnal hypoxaemiaFEV1 <1.5 LNormal or increased pCO2

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Cor PulmonaleMortality 50% at 5 years

Causes

Both obstructive and restrictive respiratory disease

Pulmonary vascular disease

Treatment

Careful O2

FrusemideVenesect if HCT >55%

Causes

PEInfection

‘Like shoes in the snow’Doesn’t clear on coughingPainful

RUB

P2Click

HEAVE

Heave/ raised JVP/ pansystolic murmur/ loud P2Hepatomegaly and pedal oedema

Pleural Rub

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Cystic Fibrosis

Delta 508 mutation

Clubbing Bibasal creps Cyanosis

Treatment

PhysioAntibioticsBronchodilatorsHeart-lung transplantationHigh dose ibuprofenAerosolised human recombinant DNaseImprove hydration of secretions with

amiloride, triphosphate nucleotideImmunisation

Treatment of steatorrhoea

Low fat dietPancreatic supplementH2 receptor antagonist

Chest infection bacteria

S. aureusH. influenzaeBurkholderia cepaciaePseudomonas aeruginosa

RIP aged 30 from respiratory complications as predicted by FEV1 <30% – gives 2 year survival

7

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Fibrosing Alveolitis

Types

UIP usualDIP desquamativeNSIP non-specificLIP lymphoidGIP giant-cell

Causes

RA/ SLE/ UC/ CAH/ SS/ dermatomyositisEAAChronic pulmonary oedemaOccupational lung disease

Features

Finger clubbingCyanosisBilateral fine late

inspiratory creps (‘velcro’)

Investigations

CXR/ ABG/ PFT/ HRCTInc ESR/ Inc Ig/ Inc ANA/

RFBAL: Lymphocytic = good

prognosis

Treatment

6/52 steroidsCyclophosphamide for

steroid non-respondersLung transplantation – has

a 60% 1 year survival

Prognostic factors

Young FemalePredominantly ground glass changesLittle fibrosisPredom lymphocytosis

LymphocytosisLittle fibrosis

Clubbing and creps differential

Bronchogenic CaBronchiectasisAsbestosisFibrosing alveolitis

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Lung Cancer

Inoperable disease

FEV1 <1.5 LCurrent IHDMalignant pleural effusionMediastinal LNCarinal involvement

Extrapulmonary

GynaecomastiaTSH raisedPTH raised

Extrapulmonary

SiADHCarcinoidACTHEaton–Lambert

Lung cancer types

Squamous (SQ) and small cell (SM) – central

Adenocarcinoma (AD) – peripheral

Treatment

Small cell – chemotxNon-small cell – surgery/radiotx

General extrapulmonary manifestations of lung cancers

CVS Endocrine Skeletal Cutaneous Neuro VascAF As above Clubbing Herpes zoster Eaton–Lambert DICPericarditis HPOA Dermatomyositis Neuropathies Marantic Horner’s endocarditis Cerebellar degeneration

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Old TB

Features

Trachea pulled overMay have obvious scarCreps upper zone

Pulmonary TB diagnosis

If sputum positive AFB: isolation for 2 weeks – can self isolate at home

Investigate contacts by enquiry re BCG/ do CXR/ Heaf testGive chemoprophylaxis if Heaf positive but CXR negativeEarly TB diagnosis done by PCR

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Pickwickian Syndrome

Features

Sleepy

Cyanosed

Short of breath

Micrognathia possibly

Obese

Right heart failure

Treatment

CPAPTonsillectomyCorrection of GH/ TSH/ OtherWeight lossMandibular surgeryTracheostomy

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Pleural Effusion

Investigations

C ytology: white cells >50 000 – parapneumonia; Lymph – Ca/ TB/ sarcoid/ collagen P rotein/ pH: If pH <7.2 suggests empyema G L ucose: glu/ LDH – TB/ Ca/ RA/ SLE; glu or LDH – in Ca poor prognosis Chol E sterol: <60 g/dL in transudates U R F: RF and ANA increased in SLE A lbumin/ ANA/ amylase: Boerhaave’s/ bact pneumonia / adenoCa/ pan L DH

Pleural effusion types

Exudate

(Serum albumin: pleural gradient >1.2 g/dL = exudate)

Lung Ca/ mesotheliomaSecondaries (breast/ lung/ ovary/ panc)Pneumonia/ TBRA/ SLE

Transudate

CCFLiver failureHypothyroidNephrotic

Empyema

Chylous

Haemothorax

Decreased movementTracheal deviation to opposite sideStony dullDecreased vocal resonance and

breath sounds (sounds travel badly through water)

Causes of dullness at the lung base

Pleural effusionPleural thickeningRaised right hemidiaphragmConsolidation and collapse

Use of USS

To differentiate thickening from effusionFor drain placementFor loculation

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Pneumothorax

Causes

SpontaneousTraumaAsthmaCOPDCa lungCFTBVentilationMarfan’sEhlers–Danlos

BTS grading

Small (<2 cm rim on CXR)MediumCompleteTension

Dec movement affected side

Inc PNDeviated tracheaDec breath soundsIf hypotensive/

tachycardic = tension

Thoracotomy if ...

a. More than three episodes of spontaneous pneumothorax

b. Bilateral pneumothoracesc. Failure of lung to expand after thoracostomy

for first episode