Respiratory

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Interstitial lung disease (most frequent by a long way!)

Bronchiectasis
Cystic fibrosis
Pneumonectomy/lobectomy
Pleural effusion
Chronic obstructive airways disease
SVC obstruction
Cor pulmonale
Apical fibrosis

Oral presentation

Tachypnoeic?
Peripheral signs
Key findings
Consistent with DD
Is there evidence of
o Asterixis?
o Cor pulmonale?
o Infective exacerbation

Interstitial lung disease

History:
Dry cough
SoB esp on exertion
Leg swelling
Occupational Hx
Hobbies
Drugs now, in past
Examination

Clubbing
Signs of steroid use
Central cyanosis
Decreased symmetrical chest expansion
Bilateral fine end inspiratory crackles

Pulmonary hypertension a wave with raised JVP, Left parasternal heave, loud P2
What are the causes of lung fibrosis?

Idiopathic pulmonary fibrosis (aka CFA, or histological diagnosis of UIP)

o Hamman-Rich syndrome is an aggressive fatal from of interstitial
pneumonitis in young, otherwise well patients with little obvious
cause. Rx supportive.

Connective tissue diseases

o Rheumatoid lung hands, nodules
o SLE facies
o Systemic sclerosis facies and hands
o Polymyositis prox muscle weakness or tenderness
o Dermatomyositis heliotrope rash and gottrons papules
o Sjorgrens syndrome
o MCTD
o Ankylosing spondylitis - posture

Drugs many
o Anti-cancer:
bleomycin
o Anti-arrhythmics:
o Anti-inflammatory:
o Anti-biotics:

esp Methotrexate, Cyclophosphamide, busulfan,

Amiodarone
Sulfasalazine, gold
Nitrofurantion, sulphonamides

Radiotherapy scars, localised, tattoos

Pneumoconioses
o Asbestosis

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Coal workers pneumoconiosis

Silicosis (silica)
Beryliosis Beryllium (lightbulbs)
Byssinosis cotton
Chalicosis stone
Bauxite fibrosis
Baritosis Barium generally benign with striking CXR abnormalities

Sarcoidosis

Extrinsic allergic alveolitis

o Alveolar inflammation due to hypersensitivity to inhaled organic
particles (Type III and IV hypersensitivity)
o Bird fanciers lung
o Cheese washers lung
o Farmers lung
o Hot tub lung
o Malt workers lung
o Millers lung
o Wood workers lung

How would you investigate a patient with fibrosis?

ABG hypoxia
CXR reticulonodular shadowing and honeycombing
Bloods incl. ESR, RF, ANA, Igs
Formal spirometry with a restrictive pattern and decreased gas transfer
HRCT
Treatment?
MDT PT, OT, SW, CNS
Oxygen, treatment of infections early
NIV if indicated
No Dx modifying Rx for IPF palliate
Reduce exposure to cause
Steroids/Aza, Cyclophosphamide
Rarely single Lung transplant
Inform about occupational health compensation
Causes of pulmonary fibrosis by zone
Upper zone
Ank spond
Carconoma
EAA
Pneumoconiosis (except Asbestosis)
TB
Middle zone
Sarcoid

Lower zone
Asbestosis
IPF/CFA
RA/SLE
Generalised
Chemotherapy
Anywhere
Radiotherapy

Pleural effusion
What are the causes?

Transudates?
o CCF
o Hypoalbuminaemia
o Renal failure
o Hypothyroidism
o Meigs syndrome right sided pleural effusion with ovarian mass
Exudate?
o Malignancy
Primary
Secondary
o Infection
Parapneumonic
Empyema
TB
o Inflammatory
Rheumatoid
SLE
o PE

How do you distinguish between a transudate or an exudates?

Classically ><30g/L
However Lights criteria more accurate
o Effusion/Serum protein >50%
o Effusion/Serum LDH >60%
o Effusion LDH > 2/3 normal range

Pneumonectomy
Examination
Deformity of chest
Flattening of lateral side
Thoracotomy scar
Tracheal deviation to that side
Decreased expansion on that side
No AE in bases
Bronchial breathing in upper zones
(Lobectomy
As above but central trachea, and diminuished AE and percussion note. )
Indications for lung resection
NSC Lung Ca
Solitary pulmonary nodules of uncertain cause
Bronchiectasis localised
Massive haemoptysis from bronchiectasis or benign or malignant lesion
TB treatment in pre-antibiotic era
Thoracoplasty
Rib removal
Less dull, more AE
If with bronchiectasis or upper lobe signs - ?old TB
What are the types of lung cancer?

What are the treatment options for lung cancer?

How do you diagnose and manage TB?

What are the causes of haemoptysis?

How would you manage haemoptysis?

Bronchiectasis
Permanent pathological dilatation of distal airways with chronic infection
Hx
SoB
Cough productive of purulent sputum
Infections
DM, diarrhoea, wt loss CF
Sinusitis Kartageners
Inflammatory disorder
Hx childhood infections
Examination
Thin
High RR
Cyanosis
Clubbing
Sputum pot with purulent sputum
Hyperexpanded chest
Coarse late insp and exp crackles with clicks and wheezes
DD of clubbing and crackles
Fibrosing alveolitis (but no clicks, wheeze or sputum)
Bronchial Ca with infection
Lung abscess
Causes
Congenital
o Primary ciliary dyskinesia
o Kartageners syndrome (as above with sinusitis, bronchiectasis, situs
inversus and infertility)
o Anatomical defects
Cystic fibrosis
Bronchial obstruction from foreign body, Cancer, granuloma, LNs
Childhood respiratory infections esp Pertussis, measles, mycoplasma
ABPA
Hypogammaglobulinaemia
Yellow-nail syndrome
Chronic aspiration
Inflammatory disorders
o RA, SLE, Sjogrens, Marfans
Investigations
Sputum MCS
CXR tramlines, ring shadows
HRCT
A1AT
Aspergillus skin prick test for ABPA

RF or CCP in RA
HIV
Sweat chloride test for CF
Exhaled NO for ciliary disorders

Treatment
PT
Abx oral or nebulised
Bronchodilators
Surgery

Findings on Pulm function tests?

Reduced FVC and FEV1 with a reduced FEV1/FVC > 70%.

Cystic fibrosis
History:
Recurrent chest infections since childhood
Productive cough with sputum
SOBOE
Symptoms of malabsorption with diarrhoea, short statue and under-weight
Symptoms of diabetes
Examination:
On observation
Short statue/ thin
Oxygen wall/concentrator
Nebuliser/ NIV
Antibiotics, mucolytics
Insulin needles or BM equipment
?Portacath/hickman line
?PEG
Gross Clubbing of fingers and toes (maybe insulin testing marks)
Lines/ scars from neck lines
Reduced expansion
Bilateral coarse crackles with pops, clicks and wheeze consistent with
bronchiectasis
Possible Cor pulmonale
What is cystic fibrosis?

What are the major medical complications of cystic fibrosis?

What is the management of cystic fibrosis?

Education
o Patient, partner, family
o Genetic testing
RFs
o smoking
o contact with MDR organisms
MDT
o Dietitian supplements/ feed
o PT postural drainage
o OT home modifications
o CNS Chest and DM
o Drs Chest, Endocrine, Gastro
o Transplant coordinators
Medical
o Bronchodilators and mucolytics
o ABx PO, IV, Nebs
o Oxygen/NIV
o Supplemental nutrition and creon
o Diabetes care with insulin and