48. Cough/sputum/wheeze/sneezing Flashcards

1
Q

what are the atopic conditions

A

asthma, eczema, hay fever and food allergies

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2
Q

presentation asthma

A

Episodic
Diurnal variability

Typical symptoms are:
Shortness of breath
Chest tightness
Dry cough
Wheeze

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3
Q

o/e asthma

A

normal when well

widespread “polyphonic” expiratory wheeze

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4
Q

what is key about the wheeze suggetsing asthma

A

WIDESPREAD

and polyphonic

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5
Q

differentials for localised monophonic wheeze

A

inhaled foreign body, tumour or a thick sticky mucus plug obstructing an airway

A chest x-ray is the next step.

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6
Q

triggers asthma

A

Infection
Nighttime or early morning
Exercise
Animals
Cold, damp or dusty air
Strong emotions

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7
Q

common drugs that can exacerbate/trigger asthma

A

beta blockers

nsaids

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8
Q

tests for making an asthma diagnosis

A
  • Spirometry with bronchodilator reversibility
  • Fractional exhaled nitric oxide (FeNO)

Where there is diagnostic uncertainty after initial investigations, the next step is testing the peak flow variability.

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9
Q

results of spirometry with reversibility testing that suggest asthma

A

reversibility = greater than 12% increase in FEV1 on reversibility testing supports a diagnosis of asthma.

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10
Q

what does FeNO test involve

A

The test involves a steady exhale for around 10 seconds into a device that measures FeNO.

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11
Q

what may impact the result of FeNO

A

Smoking can lower the FeNO, making the results unreliable.

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12
Q

FeNO positive result?

A

a level above 40 ppb is a positive test result

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13
Q

what is peak flow varibaility? what is a positive result

A

Peak flow variability is measured by keeping a peak flow diary with readings at least twice daily over 2 to 4 weeks.

NICE says a peak flow variability of more than 20% is a positive test result, supporting a diagnosis.

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14
Q

aim of treatment asthma

A

complete control of symptoms and normal lung function

No daytime symptoms.
No night-time waking due to asthma.
No need for rescue medication.
No asthma attacks.
No limitations on activity including exercise.

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15
Q

principles of asthma management

A

Start at the most appropriate step for the severity of the symptoms
Review at regular intervals based on severity (e.g., 4-8 weeks after adjusting treatment)
Add additional treatments as required to control symptoms completely
Aim to achieve no symptoms or exacerbations on the lowest dose and number of treatments
Always check inhaler technique and adherence when reviewing medications

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16
Q

what are the steps of asthma management in adults

A
  1. SABA
    • ICS
    • LTRA (e.g., montelukast)
    • LABA +/- LTRA
  2. MART inc low dose ICS
  3. MART inc moderate dose ICS
  4. Consider high-dose inhaled corticosteroid or additional drugs (e.g., LAMA or theophylline)
  5. Specialist management (e.g., oral corticosteroids)
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17
Q

when should you prescribe ICS for adults asthma

A
  • using SABA 3/7
  • symptoms 3/7
  • woken at night 1/7
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18
Q

if on SABA and ICS asthma, what should you do?

A

add Leukotriene receptor antagonist (e.g., montelukast)

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19
Q

what is COPD

A

Long-term, progressive condition involving airway obstruction, chronic bronchitis and emphysema. It is almost always the result of smoking and is largely preventable

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20
Q

what is chronic bronchitis

A

Chronic bronchitis refers to long-term symptoms of a cough and sputum production due to inflammation in the bronchi.

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21
Q

what is emphysema

A

damage and dilatation of the alveolar sacs and alveoli, decreasing the surface area for gas exchange.

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22
Q

presentation copd

A

A typical presentation of COPD is a long-term smoker with persistent symptoms of:
Shortness of breath
Cough
Sputum production
Wheeze
Recurrent respiratory infections, particularly in winter

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23
Q

what does copd not cause

A

clubbing
haemoptysis
chest pain

These symptoms should be investigated for a different cause, such as lung cancer, pulmonary fibrosis or heart failure.

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24
Q

what are the grades of the mrc dyspnoea scale

A

Grade 1: Breathless on strenuous exercise
Grade 2: Breathless on walking uphill
Grade 3: Breathlessness that slows walking on the flat
Grade 4: Breathlessness stops them from walking more than 100 meters on the flat
Grade 5: Unable to leave the house due to breathlessness

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25
what invetsigations should you do copd
spirometry with bronchodialtor reversibility testing CXR FBC BMI
26
what tests do you need for a diagnosis of copd
clinical presentation and spirometry results Spirometry will show an obstructive picture with a FEV1:FVC ratio of less than 70%. There is little or no response to reversibility testing with beta-2 agonists (e.g., salbutamol). Reversible obstruction is more suggestive of asthma.
27
why get a cxr ?copd
will show hyperinflation, bullae, flat hemidiaphragm. Also important to exclude lung cancer
28
why get fbc copd
exclude secondary polycythaemia
29
why get bmi copd
(weight loss occurs in severe disease)
30
further tests copd
ECG and echocardiogram to assess for heart failure and cor pulmonale CT thorax for alternative diagnoses such as fibrosis, cancer or bronchiectasis Serum alpha-1 antitrypsin to look for alpha-1 antitrypsin deficiency
31
non-pharmacological management points copd
smoking cessation pneumococcal and annual flu vaccine Pulmonary rehabilitation
32
1st step pharmacological copd management
SABA or SAMA
33
copd pt is on saba or sama but still uncontrolled, next step?
Do they have asthmatic features/features suggesting steroid responsiveness? Yes: Long-acting beta agonist (LABA) and Inhaled corticosteroid (ICS) (+SABA/SAMA as required) No: LABA and LAMA. if taking SAMA, switch to SABA
34
management copd
1. SABA (e.g. salbutamol) or SAMA (e.g. ipratropium bromide) 2. Do they have asthmatic features/features suggesting steroid responsiveness? Yes: Long-acting beta agonist (LABA) and Inhaled corticosteroid (ICS) (+SABA/SAMA as required) No: LABA and LAMA. if taking SAMA, switch to SABA 3. Triple therapy: LABA + LAMA + ICS (+ SABA as required) 4. Specialist guided
35
3rd line treatment copd
Triple therapy LABA + LAMA + ICS (+ SABA as required)
36
if tried triple therapy, next step copd management
Specialist guided eg theophylline
37
what criteria determines whether a pt has asthmatic/steroid resposnsive features?
any previous, secure diagnosis of asthma or of atopy a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up substantial variation in FEV1 over time (at least 400 ml) substantial diurnal variation in peak expiratory flow (at least 20%)
38
LABA and LAMA combination inhalers - examples
Anoro Ellipta, Ultibro Breezhaler and DuaKlir Genuair
39
LABA and ICS combination inhalers - examples?
Fostair, Symbicort and Seretide
40
LABA, LAMA and ICS combination inhalers - examples
Trimbow, Trelegy Ellipta and Trixeo Aerosphere triple therpay - some begin with T
41
indication LTOT COPD
chronic hypoxia (sats < 92%), cyanosis, polycythaemia, cor pulmonale
42
factors which may improve survival copd
smoking cessation - the single most important intervention in patients who are still smoking long term oxygen therapy in patients who fit criteria lung volume reduction surgery in selected patients
43
what is cor pulmonale
right-sided heart failure caused by respiratory disease
44
causes cor pulmoanle
COPD (the most common cause) Pulmonary embolism Interstitial lung disease Cystic fibrosis Primary pulmonary hypertension
45
symptoms cor pulmonale
Often patients with early cor pulmonale are asymptomatic. Symptoms of cor pulmonale include: Shortness of breath Peripheral oedema Breathlessness of exertion Syncope (dizziness and fainting) Chest pain
46
signs of cor pulmonale o/e
Hypoxia Cyanosis Raised JVP (due to a back-log of blood in the jugular veins) Peripheral oedema Parasternal heave Loud second heart sound Murmurs (e.g., pan-systolic in tricuspid regurgitation) Hepatomegaly due to back pressure in the hepatic vein (pulsatile in tricuspid regurgitation)
47
management cor pulmonale
loop diuretic LTOT
48
high yield things to remember bronchiectasis
finger clubbing Pseudomonas colonisation diagnosis by HRCT Extended courses of 7-14 days of antibiotics for exacerbations
49
what is bronchiectasis
permanent dilation of the bronchi, the large airways that transport air to the lungs. Sputum collects and organisms grow in the wide tubes, resulting in a chronic cough, continuous sputum production and recurrent infections.
50
causes of bronchiectasis
Idiopathic (no apparent cause) Postinfectious: Pneumonia Whooping cough (pertussis) Tuberculosis Alpha-1-antitrypsin deficiency Connective tissue disorders (e.g., rheumatoid arthritis) Cystic fibrosis Yellow nail syndrome
51
what is triad of yellow nail syndrome
Yellow fingernails, bronchiectasis and lymphoedema
52
presenting symptoms bronchiectasis
Shortness of breath Chronic productive cough Recurrent chest infections Weight loss
52
signs of bronchiectasis o/e
Sputum pot by the bedside Oxygen therapy (if needed) Weight loss (cachexia) Finger clubbing Signs of cor pulmonale (e.g., raised JVP and peripheral oedema) Scattered crackles throughout the chest that change or clear with coughing Scattered wheezes and squeaks
53
most common infective organisms bronchiectasis
Haemophilus influenza is most common !!!! Pseudomonas aeruginosa
54
xr findinfs bronchiectasis
Tram-track opacities (parallel markings of a side-view of the dilated airway) Ring shadows (dilated airways seen end-on)
55
what investigation is test of choice for diagnosing bronchiectasis
High-resolution CT (HRCT)
56
management infective exacerbation bronchiectasis
Sputum culture (before antibiotics) Extended courses of antibiotics, usually 7–14 days Ciprofloxacin is the usual choice for exacerbations caused by Pseudomonas aeruginosa
57
general management for bronchiectasis
general: Vaccines (e.g., pneumococcal and influenza) Respiratory physiotherapy to help clear sputum Pulmonary rehabilitation pharma: long term abx for freq infections Inhaled colistin for Pseudomonas aeruginosa colonisation Long-acting bronchodilators may be considered for breathlessness Long-term oxygen therapy in patients with reduced oxygen saturation Surgical: Surgical lung resection may be considered for specific areas of disease Lung transplant is an option for end-stage disease
58
when may a pt be on long term abx for bronchiectasis? what is the abx of choice
azithromycin) for frequent exacerbations (e.g., 3 or more per year)
59
management of pseudomonas colonisation bronchiectasis
Inhaled colistin
60
what is interstitial lung disease? what is fibrosis?
Interstitial lung disease includes many conditions that cause inflammation and fibrosis of the lung parenchyma (lung tissue). Fibrosis involves the replacement of elastic and functional lung tissue with non-functional scar tissue.
61
causes interstitial lung disease
Idiopathic pulmonary fibrosis (the most important to remember) Secondary pulmonary fibrosis: drugs/other conditions Hypersensitivity pneumonitis Cryptogenic organising pneumonia Asbestosis
62
key symptoms interstitial lung disease (ILD)
Shortness of breath on exertion Dry cough Fatigue
63
examiantion findings idiopathic pulmoanry fibrosis
Bibasal fine end-inspiratory crackles Finger clubbing
64
what does HRCT show ILD
ground glass apperance honeycombing
65
investigation of choice ILD
high-resolution CT scan (HRCT)
66
spirometry ILD
restrictive pattern
67
when there is diagnostic uncertainty interstitial lung disease, what invetsigations might you do
Lung biopsy Bronchoalveolar lavage
68
general management interstitial lung disease
Remove or treat the underlying cause Home oxygen where there is hypoxia Stop smoking Physiotherapy and pulmonary rehabilitation Pneumococcal and flu vaccine Advanced care planning and palliative care where appropriate Lung transplant is an option, but the risks and benefits need careful consideration
69
what is idiopathic pulmoanry fibrosis
Idiopathic pulmonary fibrosis features progressive pulmonary fibrosis with no apparent cause.
70
presentation idiopathic pulmonary firbosis
It presents with an insidious onset of shortness of breath and dry cough over more than 3 months. It usually affects adults over 50 years old.
71
prognosis idiopathic pulmonary fibrosis
The prognosis is poor, with a 2-5 years life expectancy from diagnosis.
72
drugs for idiopathic pulmoanry fibrosis
Pirfenidone reduces fibrosis and inflammation through various mechanisms Nintedanib reduces fibrosis and inflammation by inhibiting tyrosine kinase
73
causes of drug induced pulmaonry fibrosis
Amiodarone (also causes grey/blue skin) Cyclophosphamide Methotrexate Nitrofurantoin
74
causes of secondary pulmoanry fibrosis (Secondary to other conditions)
Alpha-1 antitrypsin deficiency Rheumatoid arthritis Systemic lupus erythematosus (SLE) Systemic sclerosis Sarcoidosis
75
what is Hypersensitivity pneumonitis/Extrinsic allergic alveolitis
involves type III and type IV hypersensitivity reaction to an environmental allergens Inhalation of allergens in patients sensitised to that allergen causes an immune response, leading to inflammation and damage to the lung tissue.
76
main invetsigation and results which suggest hypersensitivity penumonotis
bronchoalveolar lavage - Raised lymphocytes (lymphocytosis)
77
what is bronchoalveolar lavage
Bronchoalveolar lavage is performed during a bronchoscopy procedure. The airways are washed with sterile saline to gather cells, after which the fluid is collected and analysed. Raised lymphocytes (lymphocytosis) are suggestive of hypersensitivity pneumonitis.
78
specific types of hypersensitivity pneumonitis
Bird-fancier’s lung is a reaction to bird droppings Farmer’s lung is a reaction to mouldy spores in hay Mushroom worker’s lung is a reaction to specific mushroom antigens Malt worker’s lung is a reaction to mould on barley
79
presentation hypersensitivity pneumonitis
acute (occurs 4-8 hrs after exposure) dyspnoea dry cough fever chronic (occurs weeks-months after exposure) lethargy dyspnoea productive cough anorexia and weight loss
80
management hypersensitivity pneumonitis
avoid precipitating factors oral glucocorticoids Oxygen if req
81
investigation findings hypersensitivity pneumonitis
imaging: upper/mid-zone fibrosis bronchoalveolar lavage: lymphocytosis serologic assays for specific IgG antibodies blood: NO eosinophilia
82
what is cryptogenic organising pneumonia? - presentation, invetsigation, management
focal area of inflammation lung tissue - can be idiopathic or triggered by infection, drugs and inflamamtory disorders presentation: same as pneumonia, cxr same as pneumonia invetsigation: lung biopsy management: systemic corticosteroids
83
what is asbestosis
Asbestosis refers to lung fibrosis related to asbestos exposure.
84
what lung problems can asbestos cause
Lung fibrosis (asbestosis) Adenocarcinoma Mesothelioma (Pleural thickening) Pleural plaques and pleural thickening w/o the more serious diseases ^
85
what is allergic rhinitis
inflammatory disorder of the nose where the nose become sensitized to allergens such as house dust mites and grass, tree and weed pollens.
86
classifications of allergic rhinitis
seasonal perennial occupation
87
features allergic rhinitis
sneezing bilateral nasal obstruction clear nasal discharge post-nasal drip nasal pruritus
88
Management allergic rhinitis
allergen avoidance mild/mod: - oral or intranasal antihistamines mod/sev: intranasal corticosteroids a short course of oral corticosteroids are occasionally needed to cover important life events
89
why should you not used decongestents for extended periods of time
there may be a role for short courses of topical nasal decongestants (e.g. oxymetazoline). They should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis) and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal
90
what is alpha-1 antitrypsin deficiency
genetic condition caused by low levels of alpha-1 antitrypsin. Two main organs are affected by alpha-1 antitrypsin deficiency: - lungs: COPD/bronchiectasis (typically after 30 years old) - liver Dysfunction, fibrosis and cirrhosis of the liver (depending on the specific genotype)
91
inheritance alpha-1 antitrypsin deficiency
autosomal co-dominant pattern Co-dominant refers to when both gene copies are expressed and contribute to the outcome (neither is dominant or recessive over the other). The disease severity results from the combination of both copies of the gene.
92
what is alpha-1 antitrypsin
Alpha-1 antitrypsin is a protease inhibitor. Proteases therefore have free attack of tissues such as the lungs
93
how does alpha-1 antitrypsin deficiency cause liver damage
Alpha-1 antitrypsin is produced in the liver. in specific genotypes, alpha-1 antitrypsin gets trapped in the liver and is toxic to hepatocytes --> inflamamtion - fibrosis, cirrhosis and potentially hepatocellular carcinoma.
94
diagnosis of alpha-1 antitrypsin
Low serum alpha-1 antitrypsin (the screening test) Genetic testing
95
how is lung damage assessed aloha 1 antitrypsin
Chest x-ray High-resolution CT thorax Pulmonary function tests
96
management of alpha 1 antitrypsin
Non-pharmacological: Stop smoking Monitoring for complications (e.g., hepatocellular carcinoma) Screening of family members Pharmacological: Symptomatic management (e.g., standard treatment of COPD) Surgical: Organ transplant for end-stage liver or lung disease
97
liver biopsy alpha-1 antitrypsin deficiency
Liver biopsy shows periodic acid-Schiff positive staining globules in hepatocytes, resistant to diastase treatment. These represent a buildup of the mutant proteins.
98
epidemiology klebsiella
more common in diabetics and patients with a history of alcohol excess. It is also frequently caused by aspiration.
99
where in lungs does klebsiella affect
upper lobes of the lungs.
100
pneumonia in alcohol excess, aspiration or diabetes
klebsiella
101
risk factors for lung abscess
most commonly forms secondary to aspiration pneumonia poor dental hygiene, previous stroke and reduced consciousness are some of the risk factors for this
102
features lung abscess
symptoms may develop over weeks systemic features such as night sweats and weight loss may be seen fever productive cough often foul-smelling sputum haemoptysis in a minority of patients chest pain dyspnoea signs dull percussion and bronchial breathing clubbing may be seen
103
CXR lung abscess
fluid-filled space within an area of consolidation an air-fluid level is typically seen
104
management lung abscess
intravenous antibiotics if not resolving percutaneous drainage may be required and in very rare cases surgical resection
105
pulmonary fucntuon test sarcoidosis
restrictive
106
what is sarcoidosis
Sarcoidosis is a chronic granulomatous disorder. Granulomas are inflammatory nodules full of macrophages. The cause of these granulomas is unknown. It is usually associated with respiratory symptoms but has many extra-pulmonary manifestations, such as erythema nodosum and lymphadenopathy.
107
acute vs insidious sarcoidosis
acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia, purple lesions (lupus pernio) insidious: dyspnoea, non-productive cough, malaise, weight loss
108
what skin changes do you get sarcoidosis
lupus pernio - Lupus pernio is specific to sarcoidosis and presents with raised purple skin lesions, often on the cheeks and nose. Erythema nodosum - Erythema nodosum is characterised by nodules of inflamed subcutaneous fat on the shins.
109
risk factors sarcoidosis
Aged 20-39 or around 60 Women Black ethnic origin
110
what lung changes do you get sarcoidosis
Mediastinal lymphadenopathy Pulmonary fibrosis Pulmonary nodules
111
what is lofgrens syndrome?
Lofgren’s syndrome refers to a specific presentation of sarcoidosis with a classic triad of symptoms: Erythema nodosum Bilateral hilar lymphadenopathy Polyarthralgia (joint pain in multiple joints)
112
investigations sarcoidosis
Bloods: Raised angiotensin-converting enzyme (ACE) (often used as a screening test) Raised calcium (hypercalcaemia) Imaging: Chest x-ray may show hilar lymphadenopathy High-resolution CT scanning may show hilar lymphadenopathy and pulmonary nodules MRI can show central nervous system involvement PET scan can show active inflammation in affected areas Histology: helps establish the diagnosis, often by bronchoscopy with an ultrasound-guided biopsy of mediastinal lymph nodes. Histology characteristically shows non-caseating granulomas with epithelioid cells. ACE levels have a sensitivity of 60% and specificity of 70% and are therefore not reliable in the diagnosis of sarcoidosis although they may have a role in monitoring disease activity.
113
why do you get kidney stones in sarcoidosis
hypercalcaemia: macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol) hypercalcaemia
114
main CXR finding sarcoidosis
bilateral hilar lymphadenopathy
115
management sarcoidosis
Conservative management is considered in patients with no or mild symptoms. Oral steroids (for 6-24 months) are usually first-line where treatment is required. Bisphosphonates protect against osteoporosis whilst on long-term steroids. Methotrexate is a second-line option. Lung transplant is rarely required in severe pulmonary disease.
116
indications steroids sarcoidosis
stage 2 or 3 disease + symptomatic. hypercalcaemia eye, heart or neuro involvement
117
stages x-ray sarcoidosis
A chest x-ray may show the following changes: stage 0 = normal stage 1 = bilateral hilar lymphadenopathy (BHL) stage 2 = BHL + interstitial infiltrates stage 3 = diffuse interstitial infiltrates only stage 4 = diffuse fibrosis
118
prognosis sarcoidosis
Sarcoidosis spontaneously resolves in around half of patients, usually within two years. In some patients, it progresses to pulmonary fibrosis and pulmonary hypertension. Overall mortality is less than 10%.
119
histology sarcoidosis
non-caseating granulomas with epithelioid cells.
120
how to obtain sample for histology sarcoidosis
bronchoscopy with an ultrasound-guided biopsy of mediastinal lymph nodes.
121
cause bibasal altelectasis
common postoperative complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions.
122
management post-op bialteral altelectasis
positioning the patient upright chest physiotherapy: breathing exercises