Obstructive Lung disease +

Lung Cancer

Rob Nicholson
 Finals simplified

 Every Condition:

 What is it?
 What causes it?
 What do patients present with?
 How do we investigate it?
 How do we treat it acutely?
 How do we treat it chronically?
 COPD

 What is it?

 Chronic bronchitis: Cough for 3 months for 2

consecutive years.

 Emphysema: Enlarged air spaces distal to the terminal

bronchiole
COPD
 COPD

 Lung function tests:

FEV1:FVC ratio = <70%

 COPD

 What causes it?

 Smoking
 Pollution
 Alpha 1 antitrypsin
deficiency
 COPD

 What to patients present with?

 History:
 Increased SOB
 Cough (productive white normally)
 Weight loss
 Depression
 Chest pain?
COPD
 COPD

 How do we investigate it?

 History and examination

 Bloods
 Radiology
 Special tests
 COPD

 Routine bloods:

 Increased Hb: Polycythemia

 Increased inflammatory markers in an exacerbation
 COPD

 ABG:

Type I respiratory failure Type II respiratory failure

• P02 low • PO2 low
• PCO2 normal/low • PCO2 high
• pH: normal • pH: low
 COPD

Absence of
other cause of
breathlessness
Greater than 7
anterior ribs

Flattened
Diaphragm
 COPD

P-Pulmonale
 COPD

 Lung function tests:

 Decreased FEV1
 Dramatically decreased FEV1/FVC ratio
 COPD

 Treating an acute exacerbation of COPD:

 Steroids
 Nebulisers
 +/- antibiotics
 Oxygen?
 NIV?
 COPD

 Chronic:

 Stop smoking!
 COPD

 Long term treatment (pharmaceutical):

Short acting B
FEV > 50 agonist/ Short acting FEV < 50
ant muscarinic

Long acting Long acting

Long acting beta 2 Long acting beta 2
muscarinic muscarinic
agonist agonist + steroid
antagonist antagonist

One combined with

steroid

All three
 COPD

 Long term oxygen therapy.

 Differs if have cardiac disease or not

 Essentially low O2 on two separate occasions on ABG
(<7.3 if no cardiac Hx)
 Non-smokers
 Clinically stable
 Asthma
 What is it?

 Reversible airway obstruction

 Bronchial hyperactivity
 Asthma

 What do they present with?

 Increased cough (particularly bad at night)

 Diurnal variation of all symptoms
 Wheeze
 Dyspnea
 (Atopic symptoms)
 Triggers
 Asthma

 Clinical examination:

 Use of accessory muscles

 Tachycardia and tachypnea
 Widespread polyphonic wheeze
 (Signs of steroid usage)
 Asthma

 How do we investigate it?

 Bloods:

 Eosinophilia
 Raised IgE
 Asthma

 Radiology:

 Chest X-ray:

 Chronically shows the same signs as COPD. Acutely very

little
 Asthma
 Special tests:

 Spirometry: Obstructive pattern that displays >15%

reversibility.
 PEFR: diurnal variation / morning dipping
 Atopy: RAST testing and skin prick testing
 Asthma

 Treatment: Bio, psycho social……..

 Technique
 Avoidance
 Monitor
 Educate
Asthma
Asthma
Asthma
 Asthma

 Essentially:

 Under 5: Beta 2 agonist----steroid----LTA----REFER

 5-12’S: Beta 2 agonist----steroid----LOBA----increase
steroid-----oral steroids --- REFER
 Adults: Same but try everything else before referral
 Asthma

 Acute asthma:
Severity Symptoms
Mild asthma exacerbation Deterioration in normal resp
function
Moderate asthma 50-75% PEFR
exacerbation
Severe asthma exacerbation 33-50% PEFR, incomplete
sentences, RR>25, HR >110
Life threatening asthma O2 < 92%, pO2 < 8, silent
exacerbation chest, decreased conscious
level
 Asthma

 Treatment:

 Nebs
 Steroids
 Theophylline
 Magnesium sulphate
 OXYGEN
 Leukotriene
 ITU
 Lung Cancer

 What is it?

 Squamous cell carcinoma

 Adenocarcinoma
 Large cell carcinoma
 Small cell carcinoma
 Lung Cancer

 What do they present with?

 Weight loss
 Cough +/- haemoptysis
 Chest pain
 Recurrent pneumonia’s
 Hoarse voice
 Beware Horners syndrome….
 Lung Cancer

 Squamous:

 Smokers
 Centrally located
 Metastasise late
 Parathyroid hormone
 Lung Cancer

 Adenocarcinoma

 Non smokers
 Peripheral
 Metastasise early
 Lung Cancer

 Small cell lung cancer

 Starts centrally
 Rapidly progressive
 Ectopic hormone production
 (Cushings, SIADH, Carcinoid)
 Lung cancer

 Investigations:

 Bloods: FBC, Ca 2+, LFT’s, Alk phos

 Radiology: CT, MRI, bronchoscopy
 Special tests: Biopsy, cytology
 Lung Cancer

 Treatment: BIOPSYCHOSOCIAL
 MDT
 Chemo
 Radiotherapy
 Surgery
 Palliation
Example Case

Measurement Normal values

pH 7.35-7.45
pCO2 4.5-6.1
pO2 12-14
HCO3 22-28
Example case
Any questions?
 Thanks to:

 Radiology masterclass
 British lung foundation
 Google images
 BLS guidelines
 NICE guidance
 SIGN guidelines