Hints for the Respiratory Station
Chronic Obstructive Pulmonary Disease
HINTS FOR THE RESPIRATORY STATION
•Observe the patient from the end of the bed and comment on chest expansion and respiratory rate.
•Look for clues around the bedside, e.g. inhalers, spacer device, peak flow metre, nebuliser.
•Be aware of the different types of inhalers and the colour design and contents of each inhaler type.
•Always examine the contents of the sputum pot if present.
•If the patient is on oxygen, comment on delivery method and the percentage inspired if appropriate.
•Examine the patient starting from the back, as findings are more likely to be picked up from the back (important, if time is running out).
•Try to look for underlying causes of the pathology identified.
•Look for signs of cor pulmonale where appropriate.
•Complete the examination by telling the examiner you would like to check oxygen saturations, peak flow and spirometry results where appropriate.
•Use ward rounds and clinics as opportunities to practise your clinical examination skills and with presenting cases.
Please examine this patient who has a cough productive of thick sputum.
FINDINGS
•General: Age (may help with underlying diagnosis), cachexia, dyspnoea, inhalers, sputum pot (check for thick sputum ± haemoptysis), nebulisers
•Peripheral: Clubbing, signs of cor pulmonale, long line, tunnelled central venous catheter
•Chest:Coarse inspiratory crackles (which may clear with coughing), wheeze, situs inversus, scars from previous operations
PRESENTATION
On examination, this patient has evidence of bilateral coarse inspiratory crackles to the midzones and a wheeze. She also has evidence of finger clubbing, and the sputum pot by her bedside has thick dark-green-coloured sputum. The diagnosis in this patient is bronchiectasis. The patient has no evidence of cachexia, situs inversus or previous operations. In this patient, the most likely cause may be as a result of previous infection, and I would like to investigate this further.
•Comment on the patient’ s productive cough.
•Look for a sputum pot and be sure to look at the contents.
•Look for an obvious underlying cause, including: possible signs of cystic fibrosis (CF) and chronic obstructive pulmonary disease (COPD).
•If there is no obvious underlying cause, mention that the top three causes are postinfective, COPD and Cystic Fibrosis.
•Diagnosis
•Chest X-ray (CXR): May be normal, dilated bronchi with thickened walls (‘ tramline’ shadowing), ring shadowing.
•High-resolution CT (HRCT): Bronchial wall dilatation with possible thickening, airway size is greater than accompanying artery size (‘ signet ring’ appearance).
•Sputum: Send for culture and sensitivities (Pseudomonas aeruginosa is important), atypical screen, acid-fast bacilli (AFB) and fungal cultures.
•Spirometry: May show an obstructive picture (usually forced expiratory volume in first second [FEV1]/forced vital capacity [FVC] ratio < 0.7).
•Bloods: Check serum immunoglobulin levels (immunoglobulin [Ig] A, IgG, IgM) to rule out immunodeficiency as a cause, Aspergillus serology (total IgE, IgE to Aspergillus and Aspergillus precipitins).
•Investigations for the underlying cause of bronchiectasis
•Cystic fibrosis: Two measurements of sweat chloride and cystic fibrosis transmembrane conductance regulator (CFTR) genetic mutation analysis.
•Immunodeficiency: Immunoglobulin screen, functional antibody levels.
•Allergic bronchopulmonary aspergillosis (ABPA) screen.
•Ciliary dysfunction (e.g. primary ciliary dyskinesia): Saccharin test or cilial electron microscopy to assess ciliary function.
•Mechanical obstruction: Computerised tomography (CT) of the chest will locate any obstructive lesions, e.g. foreign body, lymph node compression or tumour.
MANAGEMENT
•Specialist physiotherapy with a daily routine for patients
•Antibiotics
•Treatment of acute exacerbations often requires intravenous antibiotic therapy with antipseudomonal agents (piperacillin, ceftazidime, carbapenems, aminoglycosides).
•Oral ciprofloxacin may be used.
•Long-term antibiotics may include nebulised colistin and oral macrolides.
•Bronchodilators
•In those with airflow limitation
•Mucolytics
•Carbocisteine
•Surgery
•Bronchiectasis is rarely sufficiently localised to be amenable to surgery but may be an option in a very small minority of cases.
QUESTIONS
1.What is bronchiectasis?
•Abnormal and permanently dilated airways with bronchial wall thickening.
•This is manifest as a cough with the production of thick sputum.
2.What are the causes of bronchiectasis?
•Postinfective bronchial damage: Severe bacterial and viral pneumonias, including measles and pertussis, tuberculosis (TB) and nontuberculous mycobacterial infections
•Mucociliary clearance defects: Cystic fibrosis, primary ciliary dyskinesia, Kartagener’ s syndrome, Young’ s syndrome
•Immunodeficiency: Primary (immunoglobulin deficiency) and secondary (human immunodeficiency virus [HIV] infection)
•Mechanical: Obstruction (tumour, foreign body)
•Immunological response: Allergic bronchopulmonary aspergillosis
3.What is the differential diagnosis of bilateral lower-zone crackles?
•Bronchiectasis: Coarse crackles heard in early– mid inspiration
•Lung fibrosis: Fine, late (end-inspiratory) crackles; look for clubbing, dry cough and cyanosis, as well as a cause, such as connective tissue disease
•Pulmonary oedema: Fine/coarse bibasal crackles; look for evidence of fluid overload
•Bilateral pneumonia: Coarse crackles; look for pyrexia and bronchial breathing
KEY POINTS
•On examination, coarse inspiratory crackles (that clear with coughing), along with finger clubbing, are the hallmark clinical features of bronchiectasis.
•Typical radiological signs seen on HRCT include bronchial wall thickening and the classic ‘ signet ring’ appearance of dilated bronchi.
•Ensure that you are familiar with the common causes of bronchiectasis and can list them in an ordered fashion.
REFERENCE
Pasteur MC, Bilton D, Hill AT. (2010) British Thoracic Society guideline for non-CF bronchiectasis. Thorax 65: 577.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Please examine this patient with breathlessness.
FINDINGS
•General: Dyspnoea, pursed lip breathing, prolonged expiratory time, use of accessory muscles, wheeze, presence of inhalers and oxygen
•Peripheral: Cyanosis, tar staining on finger nails, bronchodilator (fine) tremor, flap, signs of cor pulmonale
•Chest: Hyperexpanded chest, hyperresonance and reduced breath sounds (over bullae), wheeze, Hoover’ s sign (inward movement of the lower rib cage during inspiration associated with COPD)
This gentleman is dyspnoeic at rest with pursed lip breathing and is on oxygen therapy at 2 L/min. He has nicotine-stained fingernails. There is a widespread wheeze audible throughout both lung fields, and the patient has evidence of cor pulmonale. I note the presence of inhalers at the bedside, including salbutamol and a combination inhaler. The diagnosis in this patient is COPD.
•Comment on external clues, including inhalers, oxygen, nebulisers and a sputum pot.
•Comment on any features of respiratory distress and ensure the respiratory rate is counted.
•Look for features of cor pulmonale (raised jugular venous pressure [JVP], loud pulmonary component of loud second heart sound [P2], peripheral oedema), polycythaemia (plethora), infection (consolidation) and Cushing’ s syndrome (corticosteroid use).
INVESTIGATIONS
•Diagnosis
•Spirometry with bronchodilator response (to differentiate from asthma). FEV1/ FVC ratio < 0.7 and not fully reversible
•Arterial blood gas (ABG) (type 1 or 2 respiratory failure is possible)
•CXR (hyperinflation, flat hemidiaphragms, bullae, large prominent pulmonary arteries)
•Complications
•Echocardiogram (pulmonary hypertension), CXR (infection/pneumothorax/bullae)
MANAGEMENT
•Acute
•Oxygen therapy (with caution and monitoring of arterial blood gases), nebulised bronchodilators, corticosteroids, antibiotics for infection, theophylline, physiotherapy, consideration of noninvasive positive-pressure ventilation (NIPPV) and intubation for more severe cases
•Chronic: Depends on the severity of airway obstruction
•Mild
•PRN inhalers: Short-acting bronchodilator, e.g. salbutamol
•Moderate
•If still breathless and FEV1 > 50%, the patient can have a long-acting beta-agonist (LABA), e.g. salmeterol, or a long-acting muscarinic antagonist (LAMA), e.g. tiotropium.
•If still symptomatic and FEV1 < 50%, the patient can have a combination inhaler (LABA/steroid) or a LAMA.
•For patients who are still symptomatic, regardless of the FEV1, they can be prescribed a combination inhaler and a LAMA. There are also newer inhalers which are a combination of a LABA/LAMA.
•Severe
•Consider home nebulisers, theophyllines and anti-mucolytics.
•Smoking cessation advice is key and should be discussed with all patients, as well as offering nicotine replacement therapy and drugs such as varenicline and bupropion to help stop. Smoking cessation therapy is monitored using carbon monoxide (CO) readings (< 10 ppm at 4 weeks).
•Other considerations include nutritional management, pulmonary rehabilitation, vaccinations (pneumococcal and influenza), long-term oxygen therapy (LTOT), surgery, social support, psychological support and palliative care input.
QUESTIONS
1.What is cor pulmonale? What is its significance?
•Right-sided cardiac dysfunction secondary to pulmonary hypertension.
The pulmonary hypertension must be of a respiratory cause (chronic lung disease, pulmonary vasculature disorders, neuromuscular disease affecting the respiratory system).
•Untreated cor pulmonale causes right-sided heart failure and death.
2.What are the indications for LTOT?
•LTOT describes oxygen given for > 16 hours/day, with the aim of achieving a PaO2 > 8 kPa.
•It is indicated for those patients with a PaO2 < 7.3 kPa on two consecutive readings at least 3 weeks apart (in a stable patient), or for a PaO2 7.3– 8 kPa in a patient with cor pulmonale.
•All patients with an FEV1 < 30% predicted, signs of right-sided heart failure and oxygen saturations of < 92% should be considered for LTOT.
•Smoking is not a contraindication to LTOT; however, patients need to be advised of the risks associated.
3.How would you classify the severity of COPD?
•Use the National Institute for Health and Care Excellence (NICE) guidelines on classifying the severity of COPD based on the presence of symptoms and the percentage predicted of their FEV1:
•Mild: FEV1 > 80%
•Moderate: FEV1 50%– 80%
•Severe: FEV1 30%– 50%
•Very severe: FEV1 < 30%
4.What surgical interventions can be offered to patients with COPD?
•Bullectomy: In symptomatic patients who have a large bulla and FEV1 < 50% predicted.
•Lung volume reduction surgery (LVRS): This can be considered in patients who have upper-zone dominant emphysema, FEV1 > 20% predicted, PaCO2 < 7.3 kPa and transfer factor of the lung for carbon monoxide (TLCO) > 20%.
•Lung transplantation.
•Be able to identify what medications inhalers contain, from their colour/design.
•Ensure that you know the criteria for LTOT.
REFERENCES
Hardinge M, et al. (2015) BTS guidelines for home oxygen use in adults. Thorax 70: i1– 43.
National Institute for Health and Care Excellence. (2010) Guidance CG101. Chronic obstructive pulmonary disease in over 16s: Diagnosis and management. Available from https://www.nice.org.uk/guidance/cg101. Accessed 17 August 2016.
Troosters T, et al. (2005) Pulmonary rehabilitation in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 172: 19– 38.
Please examine this patient’ s respiratory system.
FINDINGS
•General: Oxygen, nebulisers, sputum pot, haemoptysis, herpes labialis, cough
•Peripheral: Tachypnoea, tachycardia, pyrexia, respiratory distress
•Chest: Decreased chest expansion, dullness to percussion over affected lobe, bronchial breathing, crackles, increased vocal resonance
PRESENTATION
This patient has evidence of consolidation at his right base. He is receiving oxygen therapy and is tachypnoeic with a respiratory rate of 28 breaths/minute. There is a sputum pot containing thick green sputum. There is dullness to percussion at the right lung base, and on auscultation, there is evidence of bronchial breathing and coarse crackles at the right base.
•Remember that in the exam situation if the information about the case is handwritten, it is likely that a patient has withdrawn from the exam at short notice and a last-minute replacement may have been recruited from the inpatient wards.
•Such a patient is likely to be more unwell than a stable patient; therefore, comment on any features of respiratory distress, note any infusions or nebulisers and check the FiO2 being delivered.
•Patients at highest risk of pneumonia include immunocompromised, COPD, elderly and alcoholic patients.
•Diagnosis
•CXR, ABG, sputum culture, routine bloods, blood cultures, atypical pneumonia screen (urine for legionella and pneumococcal antigens, mycoplasma serology) if indicated
MANAGEMENT
•Use the CURB-65 score to assess the severity of the pneumonia.
•Confusion (abbreviated mental test score [AMTS] ≤ 8)
•Urea > 7 mmol/L
•Respiratory rate ≥ 30 breaths/minute
•Blood pressure (systolic < 90 mmHg or diastolic < 60 mmHg)
•Age > 65 years
•A score of 0 or 1: Treat as an outpatient.
•A score of 2: Possible short stay in hospital.
•A score of 3– 5: Requires hospitalisation and may require critical care intervention.
•Treatment is with antimicrobials and oxygen therapy where required. In more severe cases, critical care intervention may be required.
•Antimicrobial therapy is guided by local trust guidelines, but generally use amoxicillin ± a macrolide (to cover atypical organisms in severe cases).
•Patients should be followed up after a 6-week interval with a repeat CXR to ensure that the consolidation has resolved and there is nothing sinister underlying it.
•Complications of pneumonia can include pleural effusion, empyema or a lung abscess.
QUESTIONS
1.What are the common organisms causing community-acquired pneumonia?
•Common: Streptococcus pneumoniae , Haemophilus influenzae , Staphylococcus aureus
•Atypical: Mycoplasma pneumoniae , Legionella pneumophila , Chlamydophila pneumoniae , Chlamydophila psittaci , Coxiella burnetii
•Viruses: Influenza, cytomegalovirus (CMV) and varicella-zoster
2.List possible complications of pneumonia.
•Parapneumonic effusion, empyema, cavitation, lung abscess, septic shock, respiratory failure/acute respiratory distress syndrome (ARDS), hepatitis, haemolytic anaemia, erythema multiforme
3.What is the difference between an empyema and a complicated parapneumonic effusion?
•An empyema is pus in the pleural cavity with a pH < 7.2.
•A complicated parapneumonic effusion has a pH < 7.2 but is clear.
•A parapneumonic effusion is clear with a pH > 7.2.
4.How would consolidation be differentiated from an effusion on clinical examination?
•Tactile vocal fremitus: Sound transmission is increased through tissue (consolidation) and decreased through fluid (pleural effusion).
•Whispering pectoriloquy: Is indicative of consolidation when whispered sounds are heard clearly through affected lung tissue.
5.Other than guiding the clinical management of a patient, what other information does the CURB-65 score give?
•The CURB-65 score also indicates the mortality associated with the severity of the pneumonia. A higher score is associated with a higher mortality rate:
•Score 0– 1 = < 5% mortality rate
•Score 2 = 9% mortality rate
•Score 3– 5 = 15%– 40% mortality rate
KEY POINTS
•Look closely at the information presented to the candidate, i.e. is it handwritten.
•Patients from an inpatient ward may be more unwell; comment on any respiratory distress and any infusions.
•Be aware of complications associated with pneumonia.
REFERENCE
National Institute for Health and Care Excellence. (2014) Guidance CG191. Pneumonia in adults: Diagnosis and management. Available from https://www.nice.org.uk/guidance/cg191?unlid=2520898732016221192356. Accessed 17 August 2016.
This patient has presented with repeated chest infections. Please examine their respiratory system.
FINDINGS
•General: Young patient, short stature, cachexia, pallor, dyspnoea, tunnelled central venous catheter (port-a-cath) or long line, inhalers, sputum pot, pinpricks from blood glucose measurement, nebulisers, Creon tablets, percutaneous endoscopic gastrostomy (PEG) tube
•Peripheral: Finger clubbing, signs of cor pulmonale (in patients with severe lung disease)
•Chest: Coarse inspiratory crackles (which may clear with coughing), wheeze
This young patient has cystic fibrosis. He appears cachectic and also has a port-a-cath in situ . The patient has finger clubbing and also is likely to have CF-related diabetes due to the pinpricks on his fingertips from blood glucose monitoring. On auscultation of his chest, there is evidence of coarse crackles in both lower zones in keeping with bronchiectasis.
•Comment on the patient’ s general appearance and look for any extrapulmonary manifestations. Some patients may have had a liver or renal transplant as well.
INVESTIGATIONS
•Diagnosis
•Guthrie test.
•Further genetic testing: Δ F508 is the most common mutation.
•Sweat test: Sweat sodium and chloride.
•Complications
•Chest
•Chest X-ray: Bronchial wall thickening, mucous plugging, pneumothorax
•HRCT: Bronchial wall thickening, mucous plugging, bronchiectasis (signet ring sign)
•Sputum culture: Looking for common CF pathogens, atypical infections, AFB and fungal infections
•Spirometry: Obstructive pattern
•CF-related diabetes: Oral glucose tolerance test, Hba1c, blood sugar series and continuous glucose monitoring system
•Pancreatic insufficiency: Faecal elastase levels
•CF-related liver disease: Liver function tests (LFTs), coagulation screen (assess synthetic function of liver), ultrasound scan (USS) of liver.
•Ear, nose and throat (ENT) complications (nasal polyps, sinusitis): CT scan of sinuses
•Osteoporosis/osteopenia: Dual-energy X-ray absorptiometry (DEXA) scan, parathyroid hormone (PTH), calcium and vitamin D
MANAGEMENT
•Multidisciplinary team (MDT) approach
•Respiratory physician (CF specialist), CF specialist nurse, physiotherapist, dietitian, clinical psychologist, GP, other medical teams (including endocrine and gastroenterology)
•Specialist physiotherapy
•Antibiotics (preventative nebulised antibiotics, as well as rescue courses during an acute exacerbation)
•See bronchiectasis section.
•Mucolytics
•DNase (nebulised), hypertonic saline
•Nutrition
•Special diet: High calorie/high fat, vitamins and Creon.
•Enteral feeding may be needed.
•Management of extrapulmonary complications, including CF-related diabetes and liver disease
•Psychological support
QUESTIONS
1.How common is cystic fibrosis in the UK population?
•Cystic fibrosis occurs in approximately 1 in 2500 live births.
•Cystic fibrosis is an autosomal recessive condition.
•The chance of being a carrier in the United Kingdom is 1 in 25.
2.What organisms are commonly found in the sputum of patients with cystic fibrosis, and which are most important for prognosis?
•Haemophilus influenzae , Staphylococcus aureus (commonly found in CF), Moraxella catarrhalis , Streptococcus pneumoniae , atypical mycobacteria, Aspergillus fumigatus .
•Burkholderia cepacia (in particular cenocepacia), Pseudomonas aeruginosa and Mycobacterium abcessus infection are poor prognostic indicators.
3.List the extrapulmonary manifestations of cystic fibrosis.
•Pancreatic: Malabsorption
•Endocrine: CF-related diabetes – often associated with pancreatic insufficiency
•Hepatobiliary: Gallstones, cirrhosis, portal hypertension
•Intestinal: Distal intestinal obstruction syndrome (meconium ileus equivalent) which is treated with laxatives, including gastrograffin
•Musculoskeletal: Osteoporosis, arthritis, osteopenia
•Sinusitis and nasal polyps
•Male infertility, delayed puberty
4.What are the respiratory complications caused by CF?
•Infective exacerbations
•Pneumothorax
•Haemoptysis
•Aspergillus lung disease
•Respiratory failure
5.Are you aware of any new treatments available for CF?
•Genetic modulators such as ivacaftor are now available for some CF patients with particular genetic defects, e.g. G551D.
•Ivacaftor works on chromosome 7, CFTR gene, G551D defect (7% of CF patients) by making the chloride channel functional.
KEY POINTS
•Be able to recognise these patients, taking their age and general appearance into account.
•Recognise and comment on any extrapulmonary manifestations.
•Be aware of common respiratory tract pathogens in cystic ?brosis.
Ramsey B, et al. (2011) A CFTR potentiator in patients with cystic fibrosis and the G551D mutation. N Engl J Med 365: 1663– 72.
Please examine this patient who is breathless.
FINDINGS
•General: Dyspnoea, oxygen, cachexia, tachypnoea
•Peripheral: Cyanosis (peripheral and central), clubbing, signs of cor pulmonale
•Chest: Scar (from biopsy), reduced chest expansion, fine end-inspiratory crackles
PRESENTATION
This patient has pulmonary fibrosis as evidenced by finger clubbing and fine inspiratory bibasal crackles. The likely underlying cause is systemic sclerosis, as the patient also has evidence of sclerodactyly, telangiectasiae and microstomia.
•This is a standard case which may not be included on its own in the respiratory station and may also appear in Station 5, so look for a possible underlying cause:
•Features of rheumatoid arthritis: Swan neck and boutonniè re deformities, Z-thumb, ulnar deviation at the wrist, nodules at the elbow
•Ankylosing spondylitis: ‘ Question mark’ posture
•Pacemaker and amiodarone facies
•Radiation burns and tattoos: Radiation therapy
•Features of systemic sclerosis: Sclerodactyly, telangiectasiae, beaked nose, furrowing of the mouth
•Also look for features of Cushing’ s syndrome (corticosteroid use)
INVESTIGATIONS
•Diagnosis
•ABG: Type 1 respiratory failure
•Pulmonary function tests – restrictive picture, reduced transfer factor
•CXR: Peripheral and basal reticular shadowing
•HRCT: Ground-glass appearance
•Cause
•Full history and examination, autoimmune screen, serum angiotensin-converting enzyme (ACE), bronchoalveolar lavage, transbronchial lung biopsy (TBLB) or surgical lung biopsy (if diagnostic doubt)
•Discussion at interstitial lung disease MDT
•Smoking cessation
•Pulmonary rehabilitation
•Gastric protection (e.g. proton pump inhibitors) for any patients with symptoms of reflux disease
•LTOT
•Nutritional assessment
•Psychological support
•Palliative care
QUESTIONS
1.Please describe the causes of lung fibrosis and divide them into upper- and lower-zone aetiologies.
•Upper zone
•Berylliosis, radiation, extrinsic allergic alveolitis, ankylosing spondylitis, sarcoidosis, TB (mnemonic: ‘ breast’ )
•Lower zone
•Rheumatoid arthritis and other connective tissue diseases, idiopathic, drugs (methotrexate and amiodarone), asbestosis
2.What new treatments are available for the treatment of pulmonary fibrosis (usual interstitial pneumonia [UIP] pattern)?
•Pirfenidone and nintedanib are both antifibrotics which have recently been introduced to slow down the progression of mild– moderate disease. Any patient being considered for treatment needs to be discussed at an interstitial lung disease MDT and, if they fit the required criteria, can be prescribed treatment from a specialist centre.
3.What are the pulmonary manifestations of rheumatoid arthritis?
•Lung fibrosis (which may also be secondary to methotrexate treatment)
•Pleural effusions
•Intrapulmonary nodules (including Caplan’ s syndrome)
•Obliterative bronchiolitis
KEY POINTS
•Fine end-inspiratory crackles are suggestive of fibrotic lung disease; a key differential is pulmonary oedema.
•Know the causes of pulmonary fibrosis and the lung zones they affect.
•Ensure that any management plan for a patient with pulmonary fibrosis is based around a MDT approach.
•Comment on any evidence of cor pulmonale which signifies advanced disease.
National Institute for Health and Care Excellence. (2013) Guidance CG163. Idiopathic pulmonary fibrosis in adults: Diagnosis and management. Available from https://www.nice.org.uk/guidance/CG163. Accessed 8 August 2016.
Please examine this patient who has presented with a chronic cough.
FINDINGS
•General: Cachexia (may or may not be present), lymphadenopathy, hoarse voice
•Peripheral: Finger clubbing, nicotine staining
•Chest: Scars from previous lobectomy/pneumonectomy, radiation tattoos/burns, reduced chest expansion, tracheal deviation, reduced breath sounds, dullness to percussion, possible pleural effusion
PRESENTATION
This patient appears cachectic and has finger clubbing and a hoarse voice. There are palpable cervical lymph nodes. The patient has a small blue tattoo at the front of his chest which is indicative of a radiotherapy tattoo and also has a lateral thoracotomy scar. The diagnosis in this patient would be previous lung cancer (possible recurrence with chronic cough), with the patient having had surgery and radiotherapy in the past for treatment.
Look for the following features:
•Superior vena caval obstruction (SVCO): Raised JVP, oedematous face, distended veins over chest wall and neck, respiratory distress
•Metastases
•Hepatomegaly, bony tenderness, skin lesions, cervical lymph nodes
•Paraneoplastic disorders (see below)
•Pancoast’ s syndrome (see below)
INVESTIGATIONS
•Diagnosis
•CXR: Mass, pleural effusion, bulky hilum
•CT scan: Look for evidence of masses, lymphadenopathy and metastases
•Positron emission tomography (PET) scan: For evaluation and staging of lung cancers (especially pulmonary nodules, lymph nodes and distant metastases)
•Pleural fluid cytology
•Bronchoscopy and biopsy of mass lesions
•Endobronchial ultrasound (EBUS)– guided biopsy: to assess mediastinal lymph nodes
•CT-guided lung biopsy: For peripheral lung lesions
•Biopsy of peripheral lesions to assess for metastases
•Thoracoscopy: To assess an exudative pleural effusion of unknown aetiology
MANAGEMENT
•Referral to lung MDT team.
•Dependent on staging and histology; surgical resection/chemotherapy/ radiotherapy/palliation.
•Surgical resection (pneumonectomy or lobectomy) is suitable for patients with adequate lung function and no medical contraindications.
•Refer to patient’ s functional status using the World Health Organization (WHO) performance status.
QUESTIONS
1.What are the four main histological types of lung cancer and how common are each of these?
•Lung cancer classification can be divided into small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC).
•SCLC comprises 15% of all cases, whereas NSCLC (adenocarcinoma [35%– 40%], squamous cell carcinoma [25%– 30%] and large-cell carcinoma [10%– 15%]) accounts for the remainder of lung malignancies.
•Small-cell tumours have the worst prognosis, as they have a rapid growth rate and metastasise early.
2.Which paraneoplastic syndromes are associated with lung cancer?
•Small-cell lung cancer is the most common form of cancer associated with paraneoplastic syndromes, including
•Ectopic hormone secretion: Adrenocorticotrophic hormone (ACTH) (Cushing’ s syndrome) and antidiuretic hormone (ADH) (causing syndrome of inappropriate antidiuretic hormone secretion [SIADH] – low sodium)
•Lambert– Eaton myasthenic syndrome (LEMS)
•Squamous cell carcinoma : Parathyroid hormone– related peptide release, resulting in hypercalcaemia (note that hypercalcaemia is more frequently a result of bony metastases).
•Adenocarcinoma : Hypertrophic pulmonary osteoarthropathy (HPOA); it results in gross finger clubbing and arthritis with radiological evidence of subperiosteal new bone formation.
3.What are the signs of Pancoast’ s syndrome?
•Pancoast’ s syndrome is characterised by an apical lung tumour with involvement of the brachial plexus and cervical sympathetic nerves; patients may complain of pain in the shoulder/anterior chest wall and arm weakness, and have wasting of the intrinsic muscles of the hand and an ipsilateral Horner’ s syndrome (ptosis, miosis, anhidrosis and enophthalmos).
4.What are the clinical signs and symptoms of SVCO?
•Oedema of the face, neck and upper body
•Prominent neck and chest wall vessels
•Facial plethora
•Stridor
•Headache (often worse on bending forward)
•Dizziness
KEY POINTS
•Comment on any past treatment, including surgery and radiotherapy.
•Comment on any associated complications as detailed above.
•Be able to differentiate between a pneumonectomy and lobectomy on clinical examination.
REFERENCE
Lim E, et al. (2010) Guidelines on the radical management of patients with lung cancer. Thorax 65(Suppl III): iii1– 27.
Please examine this gentleman’ s respiratory system.
FINDINGS
•General: May appear well or cachectic
•Chest: Tracheal deviation, thoracotomy scar, rib resection, decreased breath sounds with reduced chest expansion, signs of fibrosis/bronchiectasis, evidence of respiratory failure secondary to thoracoplasty
•Look for a supraclavicular scar from a phrenic nerve crush procedure, scarring from induced pneumothoraces or a lateral thoracotomy scar
PRESENTATION
This gentleman appears well with no evidence of respiratory distress. He has a scar in the left supraclavicular fossa with fine inspiratory crepitations in the left upper zone. The patient also has a left-sided chest wall deformity and a lateral thoracotomy scar. The examination findings in this patient would be consistent with old TB with a phrenic nerve crush and thoracoplasty.
INVESTIGATIONS
•CXR
•Raised hemidiaphragm on the side of phrenic nerve crush procedure, upper-lobe fibrosis, areas of cavitation
•Areas of fibrosis, loss of lung volume, thickened or calcified pleura, areas of bronchiectatic change
•Spirometry
•Postthoracoplasty may show an obstructive or restrictive defect.
MANAGEMENT
•The patient may be completely well and not need treatment.
•They may be investigated for possible recurrence of TB (bronchoscopy for a bronchoalveolar lavage) or manifestations of old TB, such as pulmonary fibrosis.
QUESTIONS
1.Outline the current drug therapies available for treatment of TB, and their side effects.
•The standard treatment for TB involves a combination of the following drugs: rifampicin, isoniazid, pyrazinamide and ethambutol. Patients are initially treated with all four drugs for the initial 2 months of therapy, followed by rifampicin and isoniazid for the subsequent 4 months; treatment is complete at 6 months.
•Multi-drug-resistant TB is that which is resistant to rifampicin and isoniazid.
•Drug-induced hepatitis
•Rifampicin, isoniazid and pyrazinamide (check LFTs prior to commencement)
•Optic neuritis
•Ethambutol (visual acuity should be documented before starting treatment)
•Peripheral neuropathy
•Isoniazid (coprescribe pyridoxine)
2.Discuss past surgical treatments of TB.
•Induced pneumothoraces
•To collapse the affected lung; procedure repeated every few weeks
•Phrenic nerve crush
•To paralyse the diaphragm and cause collapse of the underlying lung
•Plombage
•Insertion of polystyrene balls into the chest cavity to cause collapse of underlying lung
•Thoracoplasty
•Ribs around the infected cavity broken and pushed inwards to collapse underlying lung
3.What tests are used in the diagnosis of TB?
•CXR: There may be evidence of an enlarged hilum, consolidation, cavitation, pleural effusion or granulomata.
•Sputum staining: Ziehl– Neelsen staining for acid-fast bacilli.
•Biopsies of extrapulmonary manifestations, e.g. lymph nodes.
•Whole-blood interferon or skin tests (Mantoux test).
•Always consider HIV testing in patients with suspected TB.
KEY POINTS
•Be aware of the past surgical treatments for TB and the associated clinical signs.
•Be aware of the current treatment recommendations for TB.
•Be aware of the main side effects of anti-TB therapy.
Please examine this patient’ s respiratory system. They have been complaining of worsening shortness of breath.
FINDINGS
•General: Dyspnoea, oxygen and walking aids
•Peripheral: Dependent on the underlying cause (see below)
•Chest: Decreased chest expansion, trachea deviated away from side of effusion, stony-dull percussion note on affected side, decreased breath sounds on affected side
PRESENTATION
On examination, this patient has evidence of a right-sided pleural effusion. He has reduced chest expansion and a stony-dull percussion note to the right midzone with reduced breath sounds. The likely cause in this patient would be lung cancer, as he has evidence of scars that are likely from a chest drain at the right side of his chest, has finger clubbing and is cachectic.
Search for a cause for the effusion:
•Connective tissue disease: Features of rheumatoid arthritis butterfly facial rash indicative of systemic lupus erythematosus (SLE)
•Cardiac disease: Raised JVP and ankle swelling
•Lung cancer: Clubbing, wasting, Horner’ s syndrome, radiation scars, tattoos, lymphadenopathy, previous drain site scars
•Liver disease: Leuconychia, palmar erythema, spider naevi, gynaecomastia, parotid swelling, ascites
•Renal disease: Arteriovenous fistulae, scars from neck lines, peritoneal dialysis catheters, renal transplant
Also look for signs of treatment:
•Scars from pleural taps and chest drains
•CXR, pleural tap (should be US guided) sent for lactate dehydrogenase (LDH), protein, pH, amylase, glucose, cytology, microscopy and culture
MANAGEMENT
•Dependent on underlying cause and the treatment for that (e.g. infection, lung cancer), but can include the following options: therapeutic aspiration, chest drain insertion, thoracoscopy, long-term drain insertion and possible surgical interventions for an empyema
QUESTIONS
1.How would you differentiate an exudative effusion from a transudate?
•An exudative effusion is defined by
•An effusion albumin/plasma albumin ratio > 0.5
•An effusion LDH/plasma LDH ratio > 0.6
•A pleural fluid LDH > 2/3 the upper limit of normal serum LDH (Light’ s criteria)
2.What are the causes of an exudative and transudative effusion?
•Exudative
•The 4 I’ s: Infiltration (neoplasm), infection, infarction (pulmonary embolus), inflammation (rheumatoid arthritis and SLE)
•Transudative
•Cardiac failure, chronic renal disease, chronic liver disease, other rarer causes include Meigs’ syndrome
3.List some drugs that may cause a pleural effusion.
•Amiodarone
•Phenytoin
•Methotrexate
•Nitrofurantoin
•Beta-blockers
4.What is the main clinical indication for a thoracoscopy?
•The main indication for a thoracoscopy is to investigate an exudative effusion of uncertain cause, as it yields a better diagnostic rate than a pleural tap and pleural biopsies can also be taken at the same time. A thoracoscopy can also be used for therapeutic purposes with drainage of the effusion and pleurodesis during the procedure.
KEY POINTS
•Be able to differentiate between effusion and collapse (stony-dull percussion in an effusion)
•Be aware of the causes of a pleural effusion and be familiar with Light’ s criteria for classifying pleural effusions.
•Look for an underlying cause for the effusion.
PATIENT WITH PREVIOUS LUNG SURGERY
This patient is complaining of a cough; please examine their respiratory system.
FINDINGS
•General: Dyspnoea, reduced chest expansion, cachexia
•Peripheral: Finger clubbing, peripheral and central cyanosis, reduced muscle bulk under scar site, tracheal deviation towards the side of surgery (more obvious in pneumonectomy)
•Chest: Thoracotomy scar, scars from drain sites, reduced expansion on affected side, dull percussion note on the affected side, decreased breath sounds on affected side
PRESENTATION
This patient has evidence of a right-sided pneumonectomy as evidenced by the lateral thoracotomy scar, reduced chest expansion and absence of breath sounds. The absence of breath sounds suggests that the procedure has been a pneumonectomy as opposed to a lobectomy.
•Comment on the possible reason for surgery.
•Lung cancer: Clubbing, cachexia, Horner’ s syndrome, radiation scars and tattoos, lymphadenopathy
•Evidence of old TB: COPD (could have been treated with surgery for excision of large bullae and lung reduction surgery)
•Keyhole scars from video-assisted thoracoscopic surgery (VATS)
•Note: The other scenario in this station is that you have a patient who has had a lung transplant; if this is the case, you may find that the only abnormality is a ‘ clamshell’ scar.
QUESTIONS
1.How would you differentiate between a lobectomy and a pneumonectomy?
•Pneumonectomy
•The trachea is deviated away towards the side of surgery.
•Decreased breaths sounds (or no sounds) over the whole lung field.
•Reduced chest expansion.
•Lobectomy
•Trachea may be shifted away from the side of surgery.
•Audible breath sounds from the lobes that have not been operated on.
•Chest expansion may be reduced.
2.What are the criteria for lung surgery in lung cancer?
•Patients must have an FEV1 > 1.51, a transfer factor > 50%, no evidence of severe pulmonary hypertension and no evidence of metastatic disease (surgery is beneficial only in peripheral non-small-cell disease).
3.What are the indications for a lung transplant?
•Patients with emphysema (usually with alpha-1 antitrypsin deficiency), idiopathic pulmonary fibrosis, idiopathic pulmonary hypertension, bronchiectasis and cystic fibrosis may be considered for surgery.
4.What are the absolute contraindications for lung transplantation?
•Recent malignancy in the past 2 years
•Substance abuse (alcohol, smoking)
•Chest wall deformity
•Poor social support
•Psychiatric illness
•Advanced extrapulmonary organ dysfunction
•Noncurative infections: HIV
KEY POINTS
•Be able to recognise the range of thoracic scars and look for clues to guide to the underlying cause.
•Be aware of indications for lung transplantation and the major contraindications.
REFERENCE
British Thoracic Society. (2001) Guidelines on the selection of patients with lung cancer for surgery. Thorax 56: 89– 108.
•Observe the patient from the end of the bed and count the respiratory rate.
•Take a good look around the bedside and pick up on any clues that may help aid your diagnosis, e.g. sputum pot, inhalers, oxygen mask.
•Look at the inhalers to elicit their contents.
•Ensure that you have time to examine both the front and the back of the chest in your examination – concentrate on the back, as you are more likely to elicit findings and especially if you are running out of time (although this should not be the case for a well-practiced candidate).
•Be able to differentiate between consolidation and an effusion on examination.
•Look for any scars which may aid you with the diagnosis.
•If you think the diagnosis is bronchiectasis and the patient has bibasal coarse crackles, ask them to cough to see if the crackles clear.
•Be able to differentiate the causes of upper- and lower-zone fibrosis.
•In cases such as pulmonary fibrosis and pleural effusion, look for an underlying cause for the pathology.
•If you see a surgical scar, look for clues such as a radiotherapy tattoo to help guide your diagnosis.
•Familiarise yourself with pulmonary function test results for common respiratory conditions such as COPD.
•Be aware of British Thoracic Society (BTS), NICE and Scottish Intercollegiate Guidelines Network (SIGN) guidelines to help with the diagnosis and treatment of patients.