12.11.19 Ward notes

Causes of fibrosis

• Upper zone

  • B - Beryllium

  • R - Radiation

  • E - Extrinsic allergic alveolitis

  • A - Ankylosing spondylitis / Aspergillus

  • S - Silicosis

  • T - TB

  • S - Sarcoidosis

• Lower zone

  • C - Cyptogenic fibrosing alveolitis AKA Idiopathic Pulmonary Fibrosis

  • A - Asbestosis

  • R - Rheumatoid arthritis

  • D - Drugs (AMEN: Amiodarone, Methotrexate, Ergot-derivatives, Nitrofurantoin)

  • S - Systemic sclerosis

• Logic

  • Upper zones are better aerated

    • Inhaled stuff (EAA, Silicosis)

      • Except asbestos

  • Lower zones are better perfused

    • Drugs, autoimmunne

      • Except AnkSpond

Fibrosis - symptoms

• Dry cough

• Dyspnoea (progressive)

• Digital clubbing

• Diffuse inspiratory crackles

Causes of clubbing

• C - Cyanotic heart diseasse/Cystic Fibrosis

• L - Lymphoma

• U - Ulcerative colitis

• B - Bronchiectasis

• B - Bronchogenic malignancy

• I - Idiopathic pulmonary fibrosis

• N - Neoplasms

• G - Granulomatous diseases

Respiratory causes of clubbing

• A - Abcess (lung)

• B - Bronchiectasis (including CF)

• C - Cancer (lung)

• D - Decreased oxygen (hypoxia)

• E - Empyaema

• F - Fibrosing alveolitis

Endocrine paraneoplastic phenomena

• Cushing syndrome

• SIADH

• Hypercalcaemia

• Hypoglycaemia

• Carcinoid syndrome

• Polycythemia

• Hyperaldosteronism

Foster-Kennedy Syndrome

• Constellation of findings associated with tumours of the frontal lobe

• Due to optic nerve compression, olfactory nerve compression, and increased ICP secondary to a mass

  • Usually an olfactory groove meningioma

• Symptoms:

  • Optic atrophy in the ipsilateral eye

  • Papilledema in the contralateral eye

  • Central scotoma in the ipsilateral eye

  • Anosmia ipsilaterally

Emphysema subtypes

• Panacinar

  • Entire respiratory lobule, from respiratory bronchiole to alveoli, has expanded

  • Occurs more commonly in the lower lobes (especially basal segments) and in the anterior margins of the lungs

• Centriacinar

  • Respiratory bronchiole (proximal and central part of the acinus) has expanded

  • Distal acinus or alveoli are unchanged

  • Occurs more commonly in the upper lobes

• Paraseptal

  • Involves the alveolar ducts and sacs at the lung periphery

  • Emphysematous areas are subpleural in location and often surrounded by interlobular septa

• Bullous

  • Defined as being at least 1 cm in diameter, and with a wall less than 1mm thick

  • Bullae are thought to arise by air trapping in emphysematous spaces, causing local expansion

FET

• Forced expiratory time

• Good final test to do if you suspect an obstructive lung condition

• Careful though if there's a coexisting restrictive problem

Oxygen therapy guidelines in COPD

• Indications for assessment:

  • Very severe airflow obstruction - forced expiratory volume in one second (FEV1) less than 30% predicted.

  • Cyanosis

  • Polycythaemia

  • Peripheral oedema

  • Raised jugular venous pressure

  • Oxygen saturation 92% or below when breathing air

  • Consider assessment for people with severe airflow obstruction (FEV1 30-49% predicted)

• Assessment:

  • Measure ABGs on two occasions at least 3 weeks apart

• Criteria:

  • PaO2 less than 7.3 kPa when stable

  • Greater than 7.3 and less than 8 kPa when stable and with one of:

    • Secondary polycythaemia

    • Peripheral oedema

    • Nocturnal hypoxaemia

    • Pulmonary hypertension

• Use:

  • People receiving LTOT should breathe supplemental oxygen for at least 15 hours a day