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clinical Flashcards

1
Q

What is breathlessness also known as?

A

dyspnoea

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2
Q

what might be the cause of breathlessness if its severity alters at different times in the day?

A

Asthma.

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3
Q

What might be the cause of orthopnoea?

breathlessness on lying flat

A

pulmonary oedema is the most common but this is a symptom for any severe respiratory disease.

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4
Q

What might be the cause of paroxysmal nocturnal dyspnoea?

(waking up breathless in the night?

A

Pulmonary oedema or asthma.

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5
Q

What are non respiratory causes of breathlessness?

A
  1. anaemia
  2. Heart failure
  3. cardiac arrhythmias
  4. Anxiety
  5. diabetic ketoacidosis
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6
Q

What are the four classes of sputum?

A
  1. Mucoid - clear,grey or white
  2. Serous-watery or frothy
  3. Mucopurulent - yellowish tinge
  4. Purulent - dark green/yellow.
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7
Q

Do bronchogenic carcinomas cause production of mucous?

ii. What is the exception?

A

No. they cause irritation which leads to the cough reflex?

ii. rare alveolar cell carcinoma - produces copious amounts of mucoid sputum.

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8
Q

How does a bovine cough occur?

ii. what can it be a sign of ?

A

coughing relies on adequate closure of vocal chords and the raising of intra-thoracic pressure.

Bronchial tumour may prevent complete closure by effecting the laryngeal nerve. This creates a bovine cough.

ii. Lung cancers.

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9
Q

What are non respiratory causes of coughing?

A
  1. Gastroesophageal reflux

2. Postnalsal drip secondary sinusitis or drug induced.

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10
Q

What is the difference between haemoptysis and haematemesis?

A

Haemoptysis - coughing up of blood

Haematemesis - vomiting of blood.

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11
Q

What are respiratory causes of haemoptysis?

A
  1. bronchial carcinoma
  2. Pulmonary embolism— caused by DVT maybe
  3. TB
  4. Pneumonia
  5. Bronchiectasis
  6. Acute/chronic bronchitis
  7. Pulmonary vasculitis.
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12
Q

What is the difference between a polyphonic and monophonic wheeze?

A

Polyphonic- different notes - could mean widespread airflow obstruction. Asthma most likely

Monophonic- one note single airway partially obstructed. Asthma- mucus plug or tumour causing a narrowing.

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13
Q

Commonest respiratory causes of wheeze?

A
  1. COPD
  2. Asthma
  3. Pulmonary oedema
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14
Q

What is stridor?

What could be a cause ?

A
  1. Audible inspiratory noise- indicates partial obstruction of the upper,large airways.

ii. Tumour
epiglottitis

inhalation of foreign body.

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15
Q

What are the characteristics of pleural pain?

What are its causes?

A
  1. Sharp stabbing pain.

Pulmonary emboluus or infection.

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16
Q

What are the main causes of chest pain respiratory and non respiratory?

A
  1. Tietze’s syndrome - costochondral junction.
  2. Rib fracture or tumour - Bone
  3. Herpes zoster, pancoast tumour - Nerves
  4. Acid reflux - oesophagus
  5. MI,aortic dissection and aortic aneurysm - heart and vessels
  6. Pneumothorax and Pulomanry embolism (PE)- pleura
  7. Strain from coughing - muscle.
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17
Q

What could be a cause for unintentional weight loss?

A
  1. Carcinoma
  2. TB
  3. severe emphysema
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18
Q

what are the causes of ankle swelling?

A
  1. COPD

2. Cor pulmonale

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19
Q

What can childhood infections such as pneumonia lead to?

A

Bronchiectasis

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20
Q

How can you calculate number of pack years?

A

(Packs smoked per day) x (years as a smoker)

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21
Q

What is the normal respiratory rate?

A

12-20 breaths per minute

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22
Q

What is the term used to describe a breath rate higher than 20 breaths per minute?

A

Tachypnoea

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23
Q

What is the term used to describe a breath rate lower than 12 breaths per minute?

A

Bradypnoea

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24
Q

What is kussmaul respiration?

ii. What are its causes?

A

Hyperventilation with deep sighing respirations

ii. Diabetic ketoacidosis
Aspirin overdose
Acute massive pulmonary embolism

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25
Q

What is Cheyne-Stokes respiration?

ii. What are its cause?

A

Increased rate and volume of respiration by periods of apnoea.

ii. Terminal disease
Increasesd intercranial pressure

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26
Q

What causes prolongation of expiration?

A

air flow limitation.

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27
Q

What causes pursed-lip breathing?

A

Air trapping.

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28
Q

Give examples of side effects of long term use of steroids.

A
  1. rounded face
  2. Acne
  3. Hirsutism in women
  4. truncal obesity
  5. thin skin
  6. abdominal striae
  7. proximal myopathy
  8. Osteoporosis
  9. easy bruising
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29
Q

What are the respiratory causes for clubbing?

A
  1. Congenital illness
  2. cystic fibrosis
  3. bronchial caricnoma
  4. mesothelioma
  5. pulmonary metastases
  6. Empyema
  7. Bronchiectasis
  8. Lung fibrosis
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30
Q

COPD is cause of clubbing true or false?

A

false

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31
Q

Besides measuring pulse rate, what can the radial pulse be also used to calculate?

A

pulsus paradoxus. This is when there is an abnormal decrease in volume on inspiration and systolic blood pressure. Should only fall by 3-5 mm Hg , it will be pathalogical if greater than 10 mm Hg.

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32
Q

Where can the JVP be visible from?

ii. How can you make it be more visible?

A

Visible above the clavicle in between the two heads of the sternocleidomastoid.

ii. Can be accentuated by the hepatojugular reflux.

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33
Q

How can you measure the JVP?

ii. What would class it as being raised?

A

measure from the sternal notch

ii If it is greater than >4 cm

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34
Q

Define what is Kyphosis

A

Increased curvature of the spine.

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35
Q

Define what scoliosis?

A

Increased lateral curvature of the spine.

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36
Q

What might you look for in the mouth of a patient in a respiratory exam?

A
  1. candida infection- white coating on tongue - indicates steroid use or antibiotic use
  2. central cyanosis - blueness on mouth suggest a PO2 below 90% - indicates anaemia or hypovolaemia. In lung disease suggests asthma , COPD and Pulmonary Embolism.
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37
Q

What are the characteristics of Horner syndrome?

ii. What might horner syndrome mean?

A

Drooping of eye lid (partial ptosis)

Miosis (small pupil)

Anhydrosis (lack of sweating)

Enopthalmos (sunken eyeball)

ii. Pancoast tumour - presses on the sympathetic chain as it ascends the neck.

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38
Q

Where is the apex beat found?

ii. What respiratory disease might be the cause it is displaced?

A

Fifth intercostal line on the midclavicular line.

ii. Pulmonary fibrosis
Bronchiectasis
Pleural effusions
Pneumothoraces

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39
Q

What is :
i Pectus excavatum?

ii. Pectus carinatum
iii. Barrel chest? whats its cause?

A

i. Sternum is depressed in relation to the ribs.
ii. Also known as pigeon chest - sternum is more prominent than ribs
iii. Anteroposterior diameter is greater than lateral one - caused by hyperinflation in lungs.

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40
Q

What could be the causes for hyperesonant percussion?

A
  1. Pneumothorax

2. Emphysema with large bullae (fluid sac)

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41
Q

What could be the causes for dull percussion?

A
  1. Consoldiation
  2. Fibrosis
  3. Pleural thickening
  4. Collapse
  5. Infection
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42
Q

What could be the causes for stony dull percussion?

A

Pleural effusion.

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43
Q

What are the signs found in consolidation?

i. Mediastinal shift and trachea?
ii. Chest wall excursion
iii. Percussion note

IV. Breath sounds

V. Added sounds

VI. Vocal resonance.

A

i. None
ii. Normal
iii. Dull

IV. Increased

v. Crackles

VI. Increased

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44
Q

What are the signs found in Pneumothorax?

i. Mediastinal shift and trachea?
ii. Chest wall excursion
iii. Percussion note

IV. Breath sounds

V. Added sounds

VI. Vocal resonance.

A

i. None
ii. Normal
iii. Hyperesonant

IV. decreased

V. Click (occasional)

VI. Decreased

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45
Q

What are the signs found in Pleural effusion?

i. Mediastinal shift and trachea?
ii. Chest wall excursion
iii. Percussion note

IV. Breath sounds

V. Added sounds

VI. Vocal resonance.

A

i. None
ii. Decreased
iii. Stony dull

IV. decreased

V. Rub (occasional)

Vi. decreased.

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46
Q

What are the signs found in Lobar collapse?

i. Mediastinal shift and trachea?
ii. Chest wall excursion
iii. Percussion note

IV. Breath sounds

V. Added sounds

VI. Vocal resonance.

A

i. Towards
ii. Decreased
iii. Dull
iv. decreased
v. none
vi. decreased.

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47
Q

What are the signs found in pleural thickening?

i. Mediastinal shift and trachea?
ii. Chest wall excursion
iii. Percussion note

IV. Breath sounds

V. Added sounds

VI. Vocal resonance.

A

i. None
ii. Decreased
iii. Dull
iv. decreased
v. none
vi. decreased.

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48
Q

Describe what a bronchoscopy is?

ii. What are the two types?

A

Passing of a telescope via the nose or mouth into the trachea to look at large and medium sized airways

ii. Flexible fibreoptic bronchoscopy- local anaesthetic

Rigid bronchoscope- general anaesthetic

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49
Q

What is a transbronchial biopsy?

ii. What are the dangers of using it?

A

It provides samples from outside the airways e.g. parenchymal tissue. Forceps are used and are passed down the terminal bronchus.

ii. Risk of haemorrhage and pneumothorax.

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50
Q

What is sleep apnea?

ii. What is it associated with?

A

Disorder in which people stop breathring repeatedly (10-30 seconds) during their sleep.

ii. Obesity
Airway obstruction
Disorder of CNS

They also have higher incidence of hypertension.

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51
Q

What is a Endobronchial ultrasound?

ii. What is the role of this?

A

Probe which is placed down a bronchoscope.

Used for real time visualisation of deeper structures through the bronchial walls such as the lymph nodes.

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52
Q

What is a lung biopsy?

A

Sample lug lesions under the guidance of radiography.

If more extensive is required a surgical biopsy can take place. The two include Open lung biopsy and Video assistant thoracic surgery

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53
Q

What are the dangers of percutaneous fine-needle aspiration?

A

Complications may lead to pneumothorax post biopsy.

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54
Q

What is the role of a Peak flow meter?

A

It measures the maximum expiratory rate in the first 10 milliseconds of expiration.

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55
Q

What should the patient be instructed when using a peak flow meter?

A
  1. Take a full inspiration to maximum lung capacity
  2. Seal the lips tightly around the mouthpiece.
  3. Blow out forcefully into the peak flow meter, which is held horizontally.
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56
Q

What is the normal PEFR range in a healthy adult?

A

400-650 L/min

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57
Q

Suggest some conditions which would lead to a reduced PEFR.

A
  1. Asthma
  2. COPD
  3. Upper airway tumours
  4. Expiratory muscle weakness.
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58
Q

Why is PEFR not a good measure of airflow limitation?

A

Because it only measures initial expiration.

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59
Q

What is the forced expiratory volume in 1 second (FEV1)

A

Volume of air expelled in the first second of a forced expiration, starting from full inspiration.

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60
Q

What is the FVC?

A

A measure of total lung volume exhaled.

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61
Q

What is the FEV1:FVC ratio?

ii. What is the normal value?

A

Is a measure of airway limitation and allows to differentiate between restrictive and obstructive lung disease.

ii. FEV1 is 80% the value of FVC.

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62
Q

How can you differentiate between restrictive and obstructive respiratory disease using the FEV1:FVC ratio?

A

Obstructive respiratory disease

High intrathoracic pressures generated by forced expiration cause premature closure of the airways with trappings of air in the chest

FEV1 is reduced much more than FVC

FEV1:FVC ratio is reduced ( <80%)

Restrictive disease

Both FEV1 and FVC reduced,often in proportion to each other

FEV1:FVC ratio is normal or increased (>80%)

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63
Q

what does stridor or gurgling suggest?

ii. What should you do?

A

Indicates obstruction of the upper airways

ii. Tilt head lift chin. If this fails use nasopharyngeal or ororpharyngeal airway. more complex measures can be used such as Laryngeal mask airway

CALL FOR HELP.

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64
Q

What is respiratory failure?

ii. What is the main characteristic of respiratory failure?

A

Defined as a failure to maintain adequate gas exchange.

ii. PaO2 < 8 kPa - hypoxia

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65
Q

What are the types of respiratory failure?

What are the differences?

A

Type 1 - Hypoxia (Pa O2 <8KPA) with normal or low Pa CO2

Type 2- PaO2 <8 kPa. (hypoxia) - with a raised PaCO2 (>6.0 Kpa)- hypercapnia

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66
Q

What are the causes of Type 1 respiratory failure?

A

hypoventilation with V/Q mismatch

Severe acute asthma

Pneumonia

Pulmonary embolism

Pulmonary oedema

ARDS

pulmonary fibrosis

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67
Q

What are the causes of Type 2 respiratory failure?

A

Hypoventilation with or without V/Q mismatch

  1. Pulmonary

COPD

Asthma - very severe

Pneumonia - more likely type 1

Pulmonary fibrosis - more likely type 1 though

obstructive sleep apnoea

  1. Reduced respiratory drive

sedative drugs

CNS trauma

  1. Neuromuscular

Cervical cord lesions

Paralysis of diaphragm

Myasthenia gravis

Guillain- Barre syndrome

  1. thoracic wall disease- kyphoscoliosis
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68
Q

What are the signs and symptoms of respiratory failure?

A

Symptoms of underlying cause and symptoms of hypoxia and with or without symptoms of hypercapnia.

Hypoxia:

Dyspnoea

Restlessness and agitation

confusion

Cyanosis

chronic: polycythaemia, pulmonary hypertension, cor pulmonae

Hypercapnia:

Headaches

Drowsiness

Confusion

Tachycardia with a bounding pulse

Co2 flap

Peripheral vasodilation

Papilloedema

palmar erythema

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69
Q

How do you diagnose respiratory failure?

A

Blood tests -FBC, U&E, CRP, ABG

blood cultures

CXR

sputum culture

Bedside spirometry testing- for COPD and Guillan Barre syndrome

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70
Q

How do you manage Respiratory failure?

A

Treat underlying cause for both types

Type 1

Give oxygen 24-60% face mask

assisted ventilation if PaO2 <8kPA despite 60% O2

Type 2

Controlled oxygen start at 24%

recheck ABG after 20 min if PaCo2 steady or lower increase o2 concentration to 28% if still hypoxic consider assisted ventilation

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71
Q

What would over-oxygenation lead to with type 2 respiratory failure?

A

leads to suppression of ventilation and partial pressure of CO2 may rise than fall.

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72
Q

What would a rise of PaCO2 cause?

A

rise in respiratory acidosis.

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73
Q

What is the Oxygen saturation levels with those having oxygen therapy?

A

88-92%

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74
Q

What is the normal range of oxygen saturation in healthy subjects?

A

94-98%

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75
Q

What is the flow of rate and estimated percentage of oxygen delivered in:

Nasal cannulae

simple face mask

venturi mask

Nonrebreather

A

i. 2-6 L/min and 24-50%
ii. 5-15 L/min and Variable

iii. As stated on device Can achieve
exact percentage stated on mask from and 24- 60%

BLUE- 24%

WHITE -28%

YELLOW-35%

RED-40%

GREEEN-60%

IV. Usually 15L/min and 60-85%

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76
Q

What is CPAP

what is its role?

A

continuos positive airway pressure

Provides oxygen delivery added fixture positive pressure throughout the respiratory cycle. Mainly used for Type 1 failure and hypoxaemia

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77
Q

What is the range of the pressure delivered?

A

5-15 cm H20.

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78
Q

When would you use noninvasive ventilation?

A

To vary the CPAP for ventilation support.

  1. Exacerbation of Chronic obstructive disease where respiratory acidosis has higher pH than 7.35
  2. acute on chronic hypecapnic respiratory failure.
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79
Q

When would you use invasive ventilation?

A

Facial trauma or airway obstruction

Inability to protect the upper airway

Pneumothorax.

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80
Q

What is Anaphylaxis?

A

Serious allergic reaction that is potentially life threatening.

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81
Q

What type of reaction is anaphylaxis?

ii. What is it mediated by?

A

Acute type 1 immune reaction

ii. It is mediated by IgE and mast cells.

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82
Q

What are the clinical symptoms of anaphylaxis?

A
  1. Rash
  2. General itchiness
  3. Wheeze and stridor
  4. S.O.B
  5. Tachycardia
  6. Hypotension
  7. Gastrointestinal symptoms such as nausea and diarrhoea.
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83
Q

How do you manage anaphylaxis?

A

Resuscitation with Intravenous fluids and oxygen.

Intramuscular adrenaline 0.5 mL of 1:1000

Chlorphenamine 10m IM or slow IV infusion

Hydrocortisone 200 mg IM or slow IV infusion

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84
Q

Why is foreign body aspiration bad?

A

Causes airway obstruction especially bad if blocks trachea or larynx.

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85
Q

What are the clinical symptoms of foreign body aspiration?

A

In upper airways

  1. Stridor
  2. Respiratory distress
  3. Cyanosis
  4. Respiratory arrest.

Beyond the carina

  1. Recurrent cough
  2. Pneumonia
  3. S.O.B
  4. Haemoptysis.
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86
Q

What investigations can be carried out to detect foreign bodies in the airway?

A

Blood tests- may demonstrate inflammatory response

Chest X-ray

Bronchoscopy

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87
Q

How can you remove the object?

A

Bronchoscopy

encourage coughing

Heimleich manouvre ( abdominal thrusts and back slaps).

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88
Q

What is a Rhinitis?

A

Inflammation of mucosal membrane lining the nose.

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89
Q

Give examples of viruses which cause the common cold.

A

Rhinovirus

Coronavirus

Adenovirus

Parainfluenza virus

respiratory synctial virus

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90
Q

What are the symptoms of common cold?

A

Nasal obstruction

Rhinorrhoea (runny nose)

Sneezing

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91
Q

What is are pathological causes of the common cold?

A

Acute inflammation with oedema

glandular hyper-secretion

Loss of surface epithelium.

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92
Q

what are the causes of chronic rhinitis ?

A

An acute inflammatory episode.

Poor drainage of sinus

nasal obstruction by polyps

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93
Q

What are the causes of allergic rhinits?

A

IGE mediated response to common environmental allergens.

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94
Q

What is the pathological physiology for Type 1 IGE-mediated hypersensitivity reaction?

A

IGE fixes on to mast cells in nasal mucous membrane

Re exposure to allergen causes cross linking of IGE receptor on surface of mast cells

Degranulation of mast cells occurs

Release of histamine and leukotrienes.

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95
Q

What is pneumonia?

A

inflammation of the lung caused by bacteria. It is an acute lower respiratory tract infection. Alveoli are filled with inflammatory cells and lungs become solid

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96
Q

What types of pneumonia are there?

A

Community acquired pneumonia (sub type atypical community acquired pneumonia)

Hospital acquired

aspiration

pneumonia in immunocompromised patients

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97
Q

What are the causes of community acquired pneumonia?

CAP

A

Primary or secondary to underlying disease

Typical: 
Streptococcus pneumonia (most common)- rust coloured sputum and cough. acute onset  common with pre existing lung disease (gram +ve)

Moraxella catarrhalis- Common in pre-exisiting structural lung disease and in the elderly

haemophilus influenzae-Common in pre-exisiting structural lung disease and in the elderly (gram -ve)

viral pneumonia (influenza and CMV)

Atypical:

Mycoplasma pneumoniae- comes in cycles every 3-4 years common in children or elderly.

Staphlycoccus aureus- May develop from influenza. presents as Necrotising caviating pneumonia and bilateral infiltrates on CXR

Legionella species- usually acquired from contaminated water. GI upset (common) and dry cough with flu symptoms (less common). Common in smokers and young men with no co morbidities . Raised CK and positive antigen urine test and PCR sputem test and weird LFTs

Chlamydia
(most common form is chlamydophila pneumoniae)

Coxiella burnetii- rarer- found in young men and farmers. Causes endocarditis

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98
Q

What is hospital acquired pneumonia defined as?

A

Pneumonia which has developed >2 days after admission to hospitals

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99
Q

What are the common causes of Hospital acquired pneumonia? (HAP)

A

Streptococcus Pneumoniae

Anaerobic Gram negative enterobacteria

Staph aureus

Klebsiella- presents with red jelly sputum. Patients with diabetes and neuro-muscular disease are at risk. Low platelet and WCC

Costridia

aerobic Gram negative - E.COLi and acinetobacter species

pseudomonas- common in Bronchiectasis and CF

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100
Q

What is aspiration pneumonia?

A

acute aspirations of gastric contents into the lungs. Most common sites of this are right middle lobe or posterior segments of right lower lobe.

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101
Q

What can aspiration pneumonia cause?

A

Lung abscesses

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102
Q

Which groups of people are at risk of aspiration pneumonia?

A

Patients with:

  1. Strokes
  2. Bulbar palsy
  3. oesophageal disease (achalasia,reflux)
  4. intoxicated

(look for impaired swallowing or alcoholic)

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103
Q

What is the cause of aspiration pneumonia?

A

anaerobes

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104
Q

What are the causes of pneumonia in immunocompromised patients?

A

Pneumocystis jiroveci- one of the most common opportunistic pathogens. Main examination rapid desaturation on exercise or exertion.

others include

Strep pneumoniae

staph aureus

H.Influenzea

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105
Q

What are the common signs and symptoms of pneumonia?

A

SOB

Cough

purulent sputum

fevor

rigor

malaise

pleuritic pain

haemoptysis

anorexia

Signs:

Pyrexia

Tachypnoea

Tachycardia

hypotension

signs of consolidation ( reduced expansion, DULL percussion ,vocal resonance, bronchial breathing)

pleural rub

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106
Q

How do you diagnose pneumonia?

A

Oxygen saturation- have an ABG if sat less than 92%

Blood pressure

Blood tests: FBC,U&E LFT and CRP

CXR- Look for Lobar infiltrates, caviation or pleural effusion

Sputum for microscopy and culture (PCR)

Pleural fluid ay be aspirated for culture

strep pneumoniae- bronchial breathing at left lower base

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107
Q

How do you assess the severity of pneumonia?

A

CURB-65

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108
Q

when would you use CRB-65?

A

used in the community

when serum urea level is not usually available

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109
Q

What is CURB-65?

A

one point for each

Confusion- mental test <8

Urea- urea >7mmol/l

Respiratory rate- >30

BP- <91 systolic or <61 diastolic

Age->65

score

0-2 mild

3-5 severe

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110
Q

How do you manage CAP?

A

Based on CURB score

CAP

0-2(mild/moderate) -Amoxicillin 1g tds IV/PO

If penicillin allergic:Doxycycline PO 200mg on day 1 then 100mg od or IV Clarithromycin* if NBM

(total 5days)

3-5 (severe) : Co-amoxiclav IV 1.2g tds + Doxycycline PO 100mg bd

If penicillin allergic: IV Levofloxacin 500mg bd monotherapy. Levoflaxacin better than doxycycline against gram positive

(total 7 days)

ICU: Co-amoxiclav IV 1.2g tds + Clarithromycin* IV 500mg bd
If penicillin allergic: IV Levofloxacin 500mg bd monotherapy

(total 7 days)

Step down to Doxycycline 100mg bd for ALL patients with severe CAP

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111
Q

How do you manage HAP?

A

Mild/moderate: PO Amoxicillin
If penicillin allergic: Doxycycline 100mg bd

TOTAL 5 days

Severe- : IV Amoxicillin + Gentamicin
If penicillin allergic:

IV Co-trimoxazole + Gentamicin

Step down: PO Co-trimoxazole

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112
Q

How do you manage aspiration pneumonia?

A

Mild/moderate:
PO Amoxicillin + Metronidazole

If penicillin allergic: PO Doxycycline 100mg bd + Metronidazole

TOTAL 5 days

Severe:IV Amoxicillin + Metronidazole + Gentamicin

If penicillin allergic: replace amoxicillin with PO Doxycycline or IV Clarithromycin*

Step down: PO Amoxicillin + Metronidazole
If pencillin allergic: Doxycycline 100mg bd + Metronidazole

TOTAL IV/PO 7 days

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113
Q

What are the main complications of Pneumonia?

A
  1. Respiratory failure
  2. Hypotension
  3. Atrial fibrilation- common in elderly
  4. Pleural effusion
  5. Empyema
  6. Lung abscess
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114
Q

What type of chlamydia which causes pneumonia is associated with pet birds?

ii. How is it diagnosed and treated?

A

Chlamydophilila psittaci

chladmydophila serology

treat with doxycycline or clarithromycin

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115
Q

How do you treat Pneumocystis jirovercii?

A

Co trimaoxazole

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116
Q

What do Mycoplasma pneumoniae, chlaymida psittici,coxeilla and legionella all respond to?

A

Clarithromycin

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117
Q

What is empyema?

A

Pus in the pleural space

also called pyothorax

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118
Q

when should empyema be suspected?

A

if a patient with a resolving pneumonia develops recurring fever

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119
Q

what are the symptoms of empyema?

A

CXR indicates pleural effusion

aspirated pleural fluid is typically yellow and turbid

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120
Q

how do you manage empyema?

A

Drained using a chest drain inserted under radiological guidance

adhesions and loculation make this difficult

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121
Q

What is a lung abscess?

A

focus of infection with a fibrous wall

formation of cavity area of localised suppurative (pus causing) infection within the lung

pus formed in cavities

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122
Q

What are the causes of lung abcesses?

A

inadequate treated pneumonia

aspiration

bronchial obstruction

pulmonary infarction

septic emboli- septicaemia and right heart endocarditis

misplaced NG tube

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123
Q

What are the sign and symptoms of lung abscess?

A

Swinging fever

cough

purulent sputum

pleuritic pain

empyema can form

look for clubbing and anaemia

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124
Q

How do you diagnose lung abscess?

A

Blood FBC ( anaemia)

ESR, CRP and blood cultures

sputum - microscopy and culture

CXR- walled cavity with a fluid level

CT- to exclude obstruction

bronchoscopy- diagnostic specimens

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125
Q

How do you manage lung abscess?

A

antibiotics

postural drainage

may require surgical excision

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126
Q

what is bronchopneumonia?

A

infection starting in airways and spreading to adjacent alveolar lung

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127
Q

what can be an underlying cause of bronchopneumonia?

A

COPD
cardiac failure
complication of viral infection
aspiration of gastric contents

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128
Q

what is lobar pneumonia?

A

confluent consolidation involving a complete lung lobe

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129
Q

What is COPD?

A

chronic obstructive pulmonary disease- common progressive disorder characterised by airway obstruction with little or no reveresibility

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130
Q

What are the two main conditions that make up COPD?

A

emphesyma

chronic bronchitis

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131
Q

What is the epidemiology are the risk factors of COPD?

A

> 45 years old

smoking ( passive or active)
 or pollution (dust and cilica)

chronic dyspnoea

sputum production

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132
Q

What is chronic bronchitis?

A

clinically defined as cough ,sputum production on most days for 3 months of 2 successive years

histologically- caused by inflammation of airways (bronchoconstriction and mucous hyper-secretion)

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133
Q

What is emphysema?

A

Histologically- enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls. leads to loss of elastic recoil

This causes air trapping upon expiration

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134
Q

What is the pathophysiology of COPD?

A

toxins from Smoking(main reason )causes neutrophilic inflammation of the airways, alveoli and pulmonary vasculature.

increased number of goblet cells in bronchial mucosa leads to mucosal hyper-secretion due to response of inflammation

inflammation causes release of neutrophil elastase (protease) which break down alveolar wall. This upsets balance of protease and anti-protease activity.

inflammation is followed by scarring and thickening of the walls which narrows the airways. Particularly effects smaller ones.

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135
Q

What should be looked into with a patient who is younger than 45 years old and has empheysma?

A

alpha one anti-trypsin deficiency

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136
Q

What is alpha one anti-trypsin?

ii. what inhibits it?

A

protease inhibitor produced in the liver

inhibits proteolytic enzymes such as neutrophil elastase.

ii. smoking

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137
Q

What are the signs and symptoms of COPD?

A

SOB
Cough
Sputum
wheeze(caused by bronchitis)

signs: 
Tachypnoea
use of accessory muscles of respiration
hyperinflation(barrel chest)
cyanosis
reduced breath sounds (emphysema)
hyper resonant on auscultation
corpulmonae

emphysema will cause: increased pulmonary compliance, produces hyperinflated lungs and will show an obstructive defect on spirometry.

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138
Q

is emphysema reversible?

A

no

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139
Q

is chronic bronchitis reversible?

A

partially- bronchoconstriction can be reversed

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140
Q

What are the presentations of a pink puffer?

A

Patients presenting with emphysema

  1. Increased alveolar ventilation
  2. (near) Normal PaO2 and a normal (or low) PaCo2
  3. breathless but not cyanosed

potentially go onto form Type 1 resp failure

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141
Q

What are the presentations of Blue bloaters?

A

chronic bronchitis

  1. Low alveolar ventilation
  2. Low PaO2 and a high PaCo2 (hypoxia) - V/Q mismatch become insensitive to CO2 and become dependent on hypoxaemia to drive ventilation
  3. cyanosed but not breathless
  4. hypoxia leads to pulmonary hypertension and then on to Cor pulmonae
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142
Q

How do you diagnose COPD?

A

Spirometry: both reduced except FEV1 reduced to greater scale

Mild COPD: Fev1/FVC <70% FEV1 predicted >80%

moderate: FEV1/FVC <70% FEV1 predicted <80%
severe: FEV1/FVC <70% FEV1 predicted <50%

Very severe: FEV1/FVC <70% FEV1 predicted <30%

DLCO is low (in emphysema)

Bronchial challenge test : <15%- suggests irreversible

CXR: Hyperinflation, large central pulmonary arteries, decreased peripheral vascular markings, bullae

ABG: Hypoxia +/- hypercapnia

CT: if CXR is normal then use shows bronchial wall thickening, scarring and air space enlargement

FBC: packed cell volume and haemoglobin increased as a result of persistent hypoxaemia

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143
Q

How do you treat COPD?

A

General
1. Smoking cessation

  1. Flu Jab to prevent infection
  2. Exercise and diet advice
  3. Long term O2 therapy for people with patients who have a PaO2 less than 7.3KPa (55 mm Hg) or sats of <88%
    or
    7.3-8 kPa with secondary polycythamia, nocturnal hypoxia

aim is to get sats between 88-92%

pharmacological

  1. SAMA- for mild (non selective M1,m2,m3)
  2. SABA- for mild
  3. SAMA/SABA combo- for mild
  4. LAMA- tiotropium,aclidinium (selective m3)
  5. LABA
  6. LAMA/LABA/ICS combo
  7. LABA-ICS combo- salmeterol/fluticasone

remember LAMA - muscarinic antagonist
LABA - beta agonists

  1. PDE4 Inhibitor-e.g. roflumilast- never alone used for severe COPD
  2. mucolytic medicine
  3. antibiotics-e.g. azithromycin never alone

a mucolytic - may help with chronic productive cough e.g. carbocysteine

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144
Q

What are acute exacerbations of COPD?

A

acute worsening of COPD symptoms

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145
Q

What are the signs and symptoms of acute exacerbations of COPD?

A

Increasing cough/wheeze/SOB

decreased exercise capacity

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146
Q

How do you diagnose Acute exacerbation of COPD?

A

ABG

FBC: U&E, CRP

CXR to exclude pneumothorax and infection. Hyperinflated lungs

if sputum is puruelent then culture

pyrexial - blood culture

bilateral crackles and wheezing on auscultation

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147
Q

How do you manage Acute exacerbation of COPD?

A

ISOAP

Ipatroprium
Salbutamol
Oxygen
Amoxicilin
Prednisolone

No response:
i. non invasive ventilation to allow higher FiO2

ii. respiratory stimulant drug e.g. doxapram
2. consider intubation and ventilation if Paco2 is rising still despite non invasive ventilation

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148
Q

where is centriacinar emphysema?

A

distention and damage of lung tissue is concentrated around the respiratory bronchioles

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149
Q

What is pan-acinar emphysema

ii. what is it associated with

A

distention and damage affect whole lung (includes alveoli)

ii. alpha 1 antitrypsin deficiency

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150
Q

what is the difference between asthma and COPD in terms of onset?

A

Asthma -earlier onset (generally)

COPD- late onset

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151
Q

What is the difference between asthma and COPD in terms of smoking?

A

asthma not related to smoking

COPD smoking history is a major cause

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152
Q

What is the difference between asthma and COPD in terms of allergies?

A

asthma- can be allergic

COPD- always non-allergic

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153
Q

compare asthma and COPD in terms of duration of symptoms?

A

asthma- intermittent symptoms

COPD- chronic continual symtpoms

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154
Q

compare asthma and COPD in terms of disease progression?

A

asthma- not progressive

COPD- progressive

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155
Q

compare asthma and COPD in terms of cough?

A

asthma- dry cough

COPD- productive cough

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156
Q

compare asthma and COPD in terms of main immune cell mediator?

A

asthma- eosinophils

COPD- neutrophils

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157
Q

compare asthma and COPD in terms of daily variability?

A

asthma- diurnal variability

COPD- no variability

158
Q

compare asthma and COPD in terms of corticosteroid and bronchodilator response?

A

asthma- good response in both corticosteroid and bronchodilator response
COPD- poor corticosteroid and bronchodilator response

159
Q

compare asthma and COPD in terms of FVC and TLCO?

A

asthma- FVC and TLCO preserved

COPD- reduced FVC and TLCO(DLCO)

160
Q

compare asthma and COPD in terms of gas exchange?

A

asthma- normal gas exchange

COPD- impaired gas exchange

161
Q

What are the symptoms of Asthma?

A

Intermitten SOB

wheeze

cough (often nocturnal)

sputum

signs:

audible wheeze

tachypnoea

hyperinflated chest

hyper-resonant percussion note

severe attack: inability to complete sentences, pulse >110 bpm

resp rate >

162
Q

What are the three main characteristics of asthma?

A

airway narrowing

mucosal Inflammation- caused by mast cell degranulation and eosinophilic (IL 5) stimulation resulting in the release of inflammatory mediators

increased mucus production (IL 13)

163
Q

What are the environmental triggers which cause Asthma?

A
  1. Cold air
  2. allergens (house, dust mite, pollen fur)
  3. infection
  4. smoking
  5. pollution
  6. drugs (NSAIDs, Beta blockers)
164
Q

What should you ask when taking a history for asthma?

A

1.Ask about precipitants ( enviromental triggers)

  1. Diurnal variation - Worse in morning.
    Disturbed sleep?- sign of severe asthma
  2. exercise- how much can they do?
  3. Atopic?- family history of allergies, eczema, hayfever
  4. home- pets, carpet, feather pillows?,smokers?
  5. occupation- do symptoms get better on weekends or holidays? any potential triggers e.g. animal handlers
  6. Days per week off school/work due to asthma?
165
Q

what type of pathway do asthmatic pathways express?

A

Th2 pattern of cytokine expression

166
Q

what is childhood onset- asthma often accompanied with?

A

eczema- atopic dermatitis

167
Q

How do you diagnose asthma?

A

1.spirometry : shows obstructive defect-FEV1/FVC below 75%

also shows >15% improvement of FEV1 following salbutamol

  1. FENO (increased)
  2. PEFR:- measures diurnal variation

CXR: hyperinflation

Histamine or methacholine challenge- shows airway hyper-responsiveness in asthmatics. don’t use if individuals have poor lung function (FEV1 <1.5L)

skin prick tests

TLCO is normal

168
Q

How do you manage chronic asthma?

A

Lifestyle:
Quit smoking, avoid precipitants and lose weight

inhaler technique, monitor PEF- educate to enable self-management by altering their medication in the light of symptoms or PEF

  1. occasional SABA PRN e.g. salbutamol (aerosol powder, nebuliser). if used more than one daily or night -time symptoms go to step 2
  2. Add standard dose inhaled steroid e.g. beclometasone
  3. If need to add LABA e.g. salmeterol by inhaler. if works keep LABA and steroid otherwise stop LABA and increase steroid. Or use oral theophylline or Cys-LTRA (montelukast)
  4. can add oral steroids (oral prednisolone) increase doses of other drugs

anti IgE monoclonal antibodies (omalizumab) for persistent allergic asthma. one injection every 2-4 weeks

can use cromoglicate in mild and exercise asthma (always inhaled) , especially in children.

169
Q

What types of asthma are there?

A
  1. intermittent
  2. mild persistent
  3. moderate persistent
  4. severe
170
Q

What is the presentation of acute severe asthma?

A

Acute breathlessness and wheeze

unable to complete sentences

171
Q

How do you diagnose acute severe asthma?

A

PEF- may be too ill

ABG if sats are lower than 92%

life threatening features of asthma

CXR ( if pneumothorax or infection suspected)

172
Q

How do you assess severity of acute asthmatic attack?

A

severe
RR >25

Pulse >110 bpm

PEFR 30-50% of predicted

Life threatening:

Silent chest/cyanosis

arrhythmia or hypotension

exhaustion, coma

PEFR <30%

PaO2 <8Kpa and Co2 normal (hypoxia)

173
Q

How do you manage acute asthmatic attacks?

A

O SHITMAN

Oxygen - nebulised with O2
supplemental O2 94-98%

Salbutamol - (or terbutaline)

Hydrocortisone - 100 mg

Ipratropium - 4-6 hours

If not working then

Theophylline or aminophylline

consider single dose of Magnesium sulfate if no good response

IV aminophylline and or IV magnesium may buy some time while waiting for intubation and ventilation

174
Q

whats the difference between extrinsic and intrinsic asthma?

A

extrinsic- allergen caused

intrinsic- non allergen caused

175
Q

what is atopic asthma?

A

allergic asthma

176
Q

what is theophylline?

A

A methylxanthine drug with bronchodilator and anti-inflammatory action. Has many side effects and drug interactions.

177
Q

what is Fexofenadine?

A

A competitive H1 receptor antagonist used to treat allergic rhinitis.

178
Q

what is Ipratropium?

A

A short acting drug that blocks acetylcholine receptors non-selectively. Can be delivered intranasally to treat rhinorrhoea.

SABA

179
Q

what is tiotropium?

A

An anticholinergic drug, selective for M3 receptors with a long half life.

180
Q

what is Monteleukast?

A

A cysteinyl leukotriene receptor antagonist used to treat asthma and allergice rhinitis.

181
Q

what is Beclometasone?

A

An inhaled corticosteroid. Used in combination with a beta-2 adrenoceptor agonist, particularly in frequent exacerbations of COPD.

182
Q

what is Sodium cromoglicate?

A

A drug that acts as a mast cell stabiliser, used in asthma and allergic rhinitis.

183
Q

What is ARDS?

A

Acute respiratory distress syndrome- lung damage and release of inflammatory mediators cause increased capillary permeability and non-cardiogenic Pulmonary oedema.

184
Q

What are the causes of ARDS?

A

Respiratory causes: Pneumonia, Gastric aspiration, inhalation, injury, contusion

General: shock, septicaemia, haemorrhage, multiple transfusion, Pancreatitis, acute liver failure, pregnancy events (eclampsia), drugs

185
Q

What are the signs and symptoms of ARDS?

A 
Cyanosis
tachypnoea
tachycardia
peripheral vasodilation
bilateral fine inspiratory crackles
186
Q

How do you diagnose ARDS?

A

Blood:FBC U&E,LFT,CRP, clotting

blood cultures,ABG

CXR- bilateral pulmonary infiltrates

PCWP- use pulmonary artery catherter

187
Q

what is the diagnostic criteria of ARDS?

A
  1. acute onset
  2. CXR shows bilateral infiltrates
  3. PCWP: <19 mmHg or a lack of clinical congestive heart failure
  4. Refractory hypoxaemia with PaO2: FIO2 <200
188
Q

How do you manage ARDS?

A
  1. admit to ITU and give supportive therapy- treat underlying cause

Respiratory support- early ARDS may use CPAP otherwise mechanical ventilation required

  1. Circulatory support- haemodynamic monitoring
189
Q

What is the normal pH of blood?

A

7.35-7.45

190
Q

What is it called when pH falls below normal range?

A

acidosis

191
Q

What is it called when pH rises above normal range?

A

alkalosis

192
Q

Explain the values of:

  1. metabolic acidosis
  2. respiratory acidosis
  3. metabolic alkalosis
  4. respiratory alkalosis
A
  1. Low pH Normal/low PaCo2 Low HCo3-
  2. Low pH High Pa Co2. normal/high Hco3-
  3. High pH. Normal/ Paco2. high HCo3-
  4. High pH Low Paco2 Normal/Low HCo3-
193
Q

What is a pulmonary embolism

A

Obstruction of the pulmonary artery or one of its branches by an embolus.

194
Q

What are the causes of Pulmonary embolism?

A

usually a thromboembolism

  1. DVT (usually found above the knee) is main cause- passes through veins and right side of heart before lodging in the in the pulmonary arteries.
  2. RV thrombus (POST MI)
  3. septic emboli ( right-sided endocarditis)

fat embolus

195
Q

what are the main factors which cause DVT?

Virchows triad

A

Virchow’s triad:

  1. slow blood flow (stasis)

turbulent blood flow caused by Prolonged bed rest, pregnancy- baby constricts arteries. Increases risk by 6 times

  1. Hypercoagulation- altered amount of clotting factors promote haemostaisis

causes include: thrombophilia (genetic), surgery (physical damage, contraceptive pills ( increase levels of clotting factors)

  1. damage to endothelial lining-

caused by infection or toxins (smoking)

malignancy also a factor

196
Q

What are the signs and symptoms of PE?

A

Small emboli can be asymptomatic

Large emboli often fatal

Acute breathlessness

pleuritic pain

haemoptysis

dizziness

syncope

signs :

pyrexia

cyanosis

raised JVP

pleural rub

tachypnoea

tachycardia

hypotension

Signs of DVT

197
Q

What are the clinical features of DVT?

A

warm/tender, swelling calf

mild fever

pitting oedema

198
Q

How do you diagnose PE?

A
  1. CTPA- used after positive D dimer result. used to show pulmonary artery filling defect

Blood test: FBC, U&E baseline clotting

D Dimer test- if negative exclude DVT cause - sensitive but not specific

Well score <4 PE unlikely
>4 PE likely

CXR- often normal or might show oligaemia of affected segment, dilated pulmonary artery, small PE,wedge shaped-opacities

ECG- often normal or shows sinus tachycardia (also S wave in lead I and Q wave and T inversion in lead III). Right axis deviation

V/Q perfusion for pregnant women

ABG- can show decrease in PaO2 and Sao2

troponin levels can be raised

Loud pulmonary second heart sound

199
Q

How do you manage PE?

A
  1. Oxygen if hypoxic
  2. Morphine (5-10 mg) with anti emetic if the patient is in pain
  3. Iv access and start LMWH (heparin) or fandaparinux
  4. if low BP give 500 ml IV fluid bol]us
  5. a if Haemodynamically stable: if BP still low give vasopressors
    b. Haemodynamically unstable: thrombolyse
  6. Long term anticoagulation: either DOAC (switch from LMWH) or warfarin ( continue heparin till INR >2)
200
Q

what is unprovoked PE?

A

patient with no known provoking risk factors

201
Q

what is Pleural effusion?

A

Fluid in the pleural space

can be divided into 2 main subtypes based on protein concentration

Transudate <25 g/l

exudate >35 g/l

202
Q

what is a haemothorax?

A

blood in the pleural space

203
Q

what is a chylothorax?

A

lymph fluid containing fat in the pleural space

204
Q

What are the causes of pleural effusion?

A

Transudates-

  1. mainly due to increased venous pressure

cardiac failure

constrictive pericarditis

fluid overload

  1. hypoprotienaemia

Cirrhosis

nephrotic syndrome

malabsorption

3.Meigs syndrome

Exudates

  1. increased leakiness of pleural capillaries

infection (pneumonia, TB)

inflammation (rheumatoid arthritis)

malignancy ( carcinomas)

205
Q

what are the signs and symptoms of pleural effusion

A

mainly asymptomatic

  1. SOB
  2. pleuritic pain
    signs:

decreased expansion

stony dull percussion

diminished breath sounds

large effusions- may be tracheal deviation

look for signs of malignancy

206
Q

How do you diagnose Pleura effusion?

A

CXR:

Small effusions blunt costophrenic angles

large effusion- water dense shadows with conc cave upper borders

empyema- D sign

US: useful identifying pleural fluid

pleural aspiration

straw coloured- transudate, exudate

yellow- empyema

haemorrhage- trauma, malignancy, pulmonary infarction

if aspiration inconclusive then can do pleural biopsy

207
Q

How do you manage pleural effusion?

A

treat underlying cause

drainage- if symptomatic

pleurodesis with talc if effusions are recurrent. best for malignant effusions. empyema are best chest drained.

208
Q

How do you diagnose DVT?

A
  1. ultrasound doppler leg scan (1st line)

2. CT scan for ileo femoral veins, IVC and pelvis

209
Q

What is obstructive sleep apnoea?

A

intermittent closure of the pharyngeal airway causing apnoeic episodes during sleep

210
Q

what are the risk factors of sleep apnoea?

A

enlarged adenoids

obesity

middle aged man

retrognathia

hypothyroidism

stroke,MS

drugs- opiates,alcohol

post op period after anaesthesia

211
Q

what are the signs and symptoms of sleep apnoea?

A

Loud snoring

excessive daytime sleeping

poor quality sleep

morning headache

reduced cognitive performance

212
Q

what are the complications associated with sleep apnoea?

A
  1. pulmonary hypertension
  2. type 2 resp failure (acute type II resp failure is compensated respiratory acidosis)
  3. increased risk of hypertension
213
Q

how do you diagnose sleep apnoea?

A

overnight sleep study:

video recording, pulse oximetry and
polysomnography - monitors sats, airflow at mouth,ECG and abdominal wall movement in sleep

snoring and epworth score

note: 15 or more episodes in 1 hour of sleep is very serious form

214
Q

how do you manage sleep apnoea?

A

treat underlying cause (lose weight, stop drinking)

CPAP (continuous positive airway pressure) via nasal mask is most effective

mandibular advancement device- improves snoring

surgery- mandibular advancement surgery

215
Q

What is cor pulmonale?

A

right heart failure caused by chronic pulmonary arterial hypertension

216
Q

What are the causes of cor pulmonale

A

COPD

bronchiestasis

pulmonary fibrosis

severe chronic asthma

pulmonary emboli

kyphosis

scoliosis

MND

sleep apnoea

217
Q

What are the signs and symptoms of cor pulmonale

A

SOB

fatigue

syncope

signs:

cyanosis

tachycardia

raised JVP

hepatomegaly

oedema

dilated chest veins

218
Q

How do you diagnose Cor pulmonale

A

Blood: FBC- Hb and haematocrit increased

ABG- Hypoxia

CXR- enlarged right atrium and ventricle

ECG- right axis deviation, right ventricular hypertrophy

219
Q

How do you manage cor pulmonale?

A

Treat underlying cause

treat resp failure- e.g. COPD long term oxygen therapy

treat cardiac failure- diuretics e.g. furosemide or give a spironolactone

venesection- if haematocrit >55%

220
Q

What is Sarcoidosis?

A

A multi system Granulomatous (type IV hypersensitivity) disease of unknown cause.

non- caseating granulomas

221
Q

What is the epidemiology of sarcoidosis?

A

20-40yrs old

women

afro-carribean are affected more frequently

222
Q

what are the signs and symptoms of sarcoidosis?

A

can be asymptomatic

General pulmonary: dry cough, SOB, chest pain, decrease in exercise tolerance

acute:

Fever

erythema nodosum

bilateral hilar lymphodenopathy - REMEMBER MAIN ONE

arthritis

uveitis, parotitis

chronic:

Lung infiltrates

skin infiltrations

peripheral lymphadenopathy

hypercalcaemia

223
Q

How do you diagnose sarcoidosis?

A

Blood: increase in ESR, serum ACE (non specific not diagnostic). increase Ca2+ and immunoglobulins

ECG - may show aarhythmias or bundle branch block

US- may show hepatosplenomegaly or nephrocalcinosis

CT - shows peripheral nodular infiltrate

tissue biopsy- is diagnostic and shows non-caseating granulomata

first line :CXR(BHL)- show ‘punched out’ lesions in terminal phalanges

Lung function tests- may show reduced lung volumes, impaired gas transfer

224
Q

How do you manage sarcoidosis?

A

Acute sarcoidosis- Bed rest usually self limiting otherwise use NSAIDs if vital organ affected

Chronic: Prednisolone (oral steroid)

severe illness- iv methylprednisolone or immunosuppressants ( methotrexate or anti-TNF therapy)

225
Q

What are the common organs involved in sarcoidosis?

A

Lungs, lymph nodes, joints, skin, liver, eyes

Less common- kidneys, brain , nerves, heart

226
Q

What is a interstitial lung disease?

A

form of restrictive lung disease

Generic term to describe a number of conditions that primarily affect the lung parenchyma in a diffuse manner.

interferes with gas transfer and restrictive lung pattern

227
Q

What types of interstitial lung disease are there?

A

acute

episodic

chronic- part of systemic disease, known cause ,idiopathic (three types)

228
Q

What are the signs and symptoms of Interstitial Lung diease?

A

SOB

dry cough

abnormal breath sounds

abnormal CXR- shows fibrotic shadowing

restrictive pulmonary spirometry with low DLCO

229
Q

What are the pathological features ILD?

A

Fibrosis and remodelling of the interstitium

chronic inflammation

Hyperplasia of type II epithelial cells

230
Q

Give examples of ILD.

A

1.Systemic disorders:

Sarcoidosis

Rheumatoid arthritis

Systemic sclerosis

UC

autoimmune thyroid disease

  1. Known cause:

Occupational: asbestosis, silicosis, cotton worker’s lung

Drugs: nitrofurantoin, bleomycin

Hypersensitivity: hypersensitivity pneumonitis

Infection: TB, fungal

GORD

3.Idiopathic:

Idiopathic pulmonary fibrosis

231
Q

What examples of Interstitial lung disease cause upper zone fibrotic shadowing on CXR?

A

TB

Progressive massive fibrosis

radiotherapy

232
Q

What examples of ILD cause mid zone fibrotic shadowing on CXR?

A

Sarcoidosis

histoplasmosis

233
Q

What examples of ILD cause lower zone fibrotic shadowing on CXR?

A

Idiopathic pulmonary fibrosis

asbestosis

234
Q

What is extrinsic allergic alveolitis?

A

Repetitive inhalation of allergens causes a type III hypersensitivity reaction (immune complex desposition)

235
Q

what are the causes of EAA?

A

Bird-fancier’s and pigeon-fancier’s lung (proteins in bird droppings)

Farmer’s and mushroom worker’s lung (thermaoactinomyces vulgaris)

Malt worker’s lung

Sugar worker’s lung

236
Q

What are the signs and symptoms of EAA?

A

based on acute or chronic

Acute: dry cough, SOB, fever, myalgia

signs: fine bibasal crackles (no wheeze), pyrexia
chronic: Increased SOB, weight loss, cor pulmonae,
sign: hypoxia,clubbing

237
Q

How do you diagnose EAA?

A

acute

  1. FBC: for neutrophilia
  2. Raised ESR,
  3. ABG and serum antibodies

CXR: wide spread pulmonary infiltrates

reduced gas transfer during acute attacks

chronic

Blood: serum antibodies ( IgG antibodies)

CXR: pulmonary fibrosis upper zone ( looks like honey comb)

CT - nodules ground glass appearance

Lung function test: restrictive defect

238
Q

How do you manage EAA?

A

Acute: remove allergen and give O2 and oral prednisolone

chronic : allergen avoidance or wear face mask

long term steroids

239
Q

What is idiopathic pulmonary fibrosis?

A

most common cause of interstitial lung disease

Idiopathic interstitial pneumonia associated with Inflammatory cell infiltrate and pulmonary fibrosis

240
Q

What are the signs and symptoms of IPF?

A

Think 3 C’s (cough, clubbing and cyanosis)

Dry cough , SOB, weight loss, arthralgia

signs: cyanosis, finger clubbing, fine end-inspiratory crackles

241
Q

How do you diagnose IPF?

A

Blood:
ABG shows reduced PaO2 and increased PaCO2.

Raised CRP and immunoglobulins

spirometry: Restrictive pattern ( decreased FEV1 and FVC) normal ratio

lung biopsy: may be needed for diagnosis

CXR: lower zone reticulo nodular shadowing. In advanced cases Honey comb

CT: ground glass

BAL: may indicate activity of alveolitis: increased lymphocytes (good prognosis), neutrophils and eosinophils ( poor prognosis)

242
Q

How do you manage IPF?

A

Supportive care: oxygen, pulmonary rehabilitation, palliative care

potential lung transplantation if young

antifibrotic agent : Pirfenidone and Nintedanib

overall shit prognosis: 50% will die in 5 years

243
Q

how is fibrosis shown on CXR?

A

honey-combing

244
Q

what is pneumoconiosis?

A

A general term for a fibrotic lung disease induced by inhaling particles of dust. The principal varieties are anthracosis, asbestosis, and silicosis, caused by inhaling coal dust, asbestos fibers, and silica dust, respectively.

245
Q

What is coal worker’s pneumoconiosis?

A

Common dust disease in countries that have underground mines. Results from inhalation of coal dust particles.

absorption of particles via macrophages cause release of enzymes leading to fibrosis

246
Q

What are the signs and symptoms of coal worker pneumoconiosis?

A

Usually asymptomatic

can have co existing chronic bronchitis

247
Q

How do you diagnose CWP?

A

CXR: many round opacities especially in upper zone (nodular shadowing)

248
Q

How do you manage CWP?

A

avoid exposure to coal dust

treat chronic bronchitis

claim compensation!

249
Q

What is progressive massive fibrosis?

A

upper mid zone fibrosis forme due to progression of CWP

250
Q

What are the signs and symptoms of progressive massive fibrosis?

A

worsening SOB

fibrosis – then cor pulmonae

251
Q

How do you diagnose PMF?

A

CXR : shows bilateral upper mid zone fibrotic masses develop from periphery

spirometry-restrictive pattern

252
Q

How do you manage PMF?

A

avoid exposure to coal dust

253
Q

What is caplan’s syndrome?

A

rheumatoid pneumoconosis (pulmonary nodules)

254
Q

What is silicosis caused by?

A

inhalation of silica particles which are fibrogenic

jobs included are: metal mining, stone quarrying, sand blasting and pottery manufacture

255
Q

what are the signs and symptoms of silicosis?

A

progressive SOB

256
Q

How do you diagnose silicosis?

A 
CXR-
shows fibrosis (nodular pattterns in upper and mid zones

shows egg-shell calcification of hilar nodes

spirometry: restrictive ventilatory defect

257
Q

How do you manage silicosis?

A

avoid exposure to silica

258
Q

What is asbestosis caused by?

A

inhalation of asbestos fibres

asbestos is found in fire proofing, electrical wire insulation and roofing

259
Q

What are the signs and symptoms of asbestosis?

A

progressive SOB, clubbing and find end inspiratory crackles (typical fibrotic lung disease)

also causes pleural disease- causes pleural plaque increasing risk of bronchial adenocarcinoma and mesothelioma

diagnosis: ground glass appearance on HRCT

260
Q

what are the 2 types of asbestos fibres?

A

serpentine (curved)- safer cant get stuck in large airways

straight

261
Q

what type of lung biopsies can you take?

A 
transbronchial biopsy (during bronchoscopy)
thoracoscopic biopsy (minor thoracic surgery)
262
Q

what is the formation of pleural disease?

A
  1. benign pleural plaque
  2. acute asbestos pleuritis- “difficult to catch breath” constant dull ache
  3. PE and diffuse pleural thickening
  4. Maligant mesothelioma
263
Q

What is pneumothorax?

A

air in the pleural cavity which can lead to lung collapsing.

264
Q

What is spontaneous pneumothorax?

A

Pneumothorax which has occurred in normal lungs

common in young tall thin men

most likely cause is rupture of a subpleural rupture (primary)

or underlying lung diease (secondary)

265
Q

what are the other causes of pneumothorax?

A
  1. chronic lung diseases: Asthma, COPD,CF, Lung fibrosis
  2. Infection: TB, Pneumonia, lung abscess
  3. Traumatic: including iatrogenic
  4. carcinoma
  5. Marfan’s syndrome
266
Q

What are the signs and symptoms of Pneumothorax?

A

Can be asymptomatic- mainly primary spontaneous

sudden onset SOB,

sudden onset pleuritic chest pain

hypoxia

signs:

Reduced expansion

hyper resonance to percussion

tachycardia

quiet breath sounds on auscultation

hamman’s sign (click on auscultation left side)

267
Q

How do you diagnose pneumothorax?

A

Lung collapse - chest wall expanded

CXR: look for area devoid of lung markings, peripheral to edge of collapsed lung

small <2cm rim of air

large= >2cm rim of air

measured at visible lung margin at level of hilum

check ABG if hypoxic

left upper lobe collapse: CXR: oblique fissure seems to be very anterior (Displaced), and on PA chest X-ray left heart border is obscured and there is a veil-like opacity.

left lower lobe collapse- CXR: left oblique fissure is displaced, and the medial left hemidiaphragm is obscured

right upper lobe collapse:On PA chest X-ray right horizontal fissure is displaced. There is an opacity in his upper right zone

268
Q

How do you manage pneumothorax?

A

<2cm and no SOB- no treatment

Primary pneumothorax

  1. If SOB and/or rim of air >2cm on CXR then aspiration (1st line)
  2. continue with chest drain (4th or 5th intercostal space in the mid axillary line). - safe triangle. also used if aspiration not successful

first use chest drain for pneumothorax caused by mechanical ventilation or trauma

Secondary pneumothorax

  1. SOB or rim of air >2cm then chest drain

only aspire for secondary if 1-2 cm and SOB

Aspire: insert 16g cannula into mid clavicular line of 2nd intercostal space

surgery:
secondary ipsilateral pneumothorax
First contralateral pneumothorax
bilateral pneumothoraces

failure to expand after 48hour drainage

persistent air leak ( use pleurodesis)

follow up: discuss flying and diving after, risk of recurrence and smoking cessation

269
Q

What is tension pneumothorax?

A

Very serious form -a breach in the lung surface acts as one way valve when breathe in but is prevented from leaving when breathing out

270
Q

What will happen if tension pneumothorax is not fixed?

A

cardiorespiratory arrest

271
Q

why is tension pneumothorax so serious?

A

as the pressure build up cause the mediastinum to push over into the contralateral hemithorax kinking and compressing the great veins

272
Q

what are the signs and symptoms of Tension pneumothorax?

ii. how do you differentiate between simple and tension pneumothorax

A

SOB pleuritic pain

Acute Respiratory distress

signs
tachycardia

tachypnoea

hypotension

distended neck veins

trachea deviated opposite side of pneumothorax (contralateral)

raised JVP

reduced breath sounds

increased percussion note

right sided tension pneumothorax: right side is hyperresonant when percussed. PA chest X-ray shows a line parallel to the right chest wall.

ii. Palpate trachea- simple pneumothorax does not cause deviation of trachea. while tension does

273
Q

How do you manage tension pneumothorax?

A

1.Needle compression (14-16g) into 2nd intercostal space in the midclavicular line on the side of pneumothorax

usually a large bore venflon can be used alternatively

2nd. insert a chest drain ( 4th or 5th intercostal space in the mid axillary line)

only have a CXR after treatment do not delay

274
Q

What is bronchiectasis?

A

widening of the bronchi or their branches

275
Q

what is the pathophysiology of bronchiectasis?

A

chronic inflammation of the bronchi and bronchioles leads to permanent dilation and thinning of airways.

Main organisms : h.influenzae , strep pneumoniae , staph aureus, pseudomonas aeruginosa - common in CF

276
Q

what are the causes of bronchiectasis?

A

Congenital : CF, young’s syndrome , Kartagener’s syndrome

Post-infection: Measles, Bronchilitits, pneumonia, TB, HIV

other: Bronchial obstruction, UC, idiopathic and rheumatoid arthiritis

277
Q

What are the signs and symptoms of bronchiectasis?

A

Symptoms : persistent cough, persistent purulent sputum , intermittent haemoptysis

signs: Finger clubbing, inspiratory crepitations, wheeze coarse crackles

278
Q

How do you diagnose bronciectasis?

A

Sputum: culture

CXR: cystic shadows and thickened bronchial walls ( tramline and ring shadows)

Spirometry: shows obstructive pattern

bronchoscopy: locate haemoptysis

HR CT: shows signet ring sign due to bronchioles being wider than neighbours

can do CF sweat test

serum immunoglobulins

279
Q

How do you manage bronchiectasis?

A

Airway clearance techniques and mucolytics - chest physiotherapy and flutter valve aid sputum removal and mucus drainage

Antibiotics based on sensitivities of patient

bronchodilatiors e.g. nebulised salbutamol

corticosteroids (e.g. prednisolone)

nebulised saline

surgery to control severe haemoptysis

280
Q

What is cystic fibrosis

A

autosomal recessive condition caused by mutations in the CFTR gene on chromosome 7

1:25

281
Q

what is the pathophysiology of cystic fibrosis?

A

CFTR gene codes for Cl- channel. Defect leads to combination of defective Chloride secretion and increased sodium absoprtion across airway epithelium.

mucous production is more thick and sticky leading to blockage of intestinal glands, prancreas and bronchioles

282
Q

what are the signs and symptoms of cystic fibrosis?

A

Neonate: failure to thrive, meconium ileus,rectal prolapse

children and young adults :

Respiratory : cough, wheeze, recurrent infections, bronchiectasis, pneumothorax, haemoptysis, respiratory failure ,cor pulmonae

GI: Pancreatic insufficiency ( Diabetes mellitus and steatorhoea) , Gall stones, liver failure

General : weight loss, clubbing

male infertility

283
Q

How do you diagnose cystic fibrosis?

A

Sweat test: sodium and chloride >60mmol/L

genetic screening

culture-pseudomonas aeruginosa can be present

284
Q

How do you manage CF?

A

chest physiotherapy (postural drainage, airway clearance)

prophylactic antibiotics. cirprofloxacin for pseudomonas

Mucolytics may be useful

pancreatic enzyme replacement

fat soluble vitamin supplements

if cirrhotic then lung transplantation

other: treatment of CF diabetes

basically there is a shit tonne of stuff you can do it all depends on the symptoms

prognosis: 40 years old

285
Q

what is bronchial carcinoma?

ii. what are its main risk factors?

A

bronchial carcinoma-A lung mass that is a primary pulmonary condition that can cause systemic effects and B symptoms, and can metastasis

Cigarrette smoking

passive smoking

asbestos

286
Q

what is the histology of bronchial carcinoma?

A

2 main sub types Non small cell and small cell

Non small cell:
squamous,
adenocarcinoma,
large cell (classed as neither squamous or adenocarcinoma)

adenocarcinoma in situ (rare)

small cell:from endocrine cells often secreting polypeptide hormones resulting in paraneoplastic syndromes

287
Q

What are the signs and symptoms of Bronchial carcinoma?

A

Symptoms : cough, haemoptysis, SOB, chest pain, weight loss, anorexia, recurrent pneumonia, hoarseness and stridor

symptoms of metastasis

bone pain

confusion and neurological deficits

myopathy, peripheral neuropathy

signs: Cachexia, anaemia, clubbing , HPOA- causing wrist pain, raised JVP, supraclavicular or axillary nodes

respiratory : none otherwise, consolidation , Pleural effusion

GI: hepatosplenomegaly

288
Q

What are the complications of bronchial carcinoma?

A

Metastatic

Recurrent laryngeal nerve palsy- hoarseness

SVC obstruction-causes puffy eyelids and headaches

Horner’s syndrome

pericarditis

cerebral metastases- weakness, headache (worse in morning, no photophobia), fits

  1. non metastatic: paraneoplastic

finger clubbing

hypertrophic pulmonary oesteoarthropathy (HPOA)

weight loss

hypercalcaemia- causes headaches, constipation and thirst

SIADH

289
Q

how do you diagnose bronchial carcinoma?

A

blood: FBC, U&E and LFT

CXR: first line looks for peripheral nodule, hilar lymphadenopathy (enlargement) , pleural effusion and bony secondaries

squamous cells carcinoma usually centrally located. Most common cause of caviating lesion

PET scan to help stage CT also useful for staging

CT guided bronchoscopy- give histology and also allow for biopsy

Endobronchial ultrasound- enables visualisation of hilar and mediastinal structure and can target and sample lymph nodes

medical thorascopy- under sedation scope inserted between rib spaces. lung deflated to allow visualisation of pleural surface. Biopsy from pleura can be taken

cytology: sputum and pleural fluid- time consuming task for pathologist and rarely changes the management

can do aspiration of pleural fluid

290
Q

what 6 structures can a lung tumour locally invade into?

A 
recurrent laryngeal nerve
pericardium
oesophagus-causes dysphagia
brachial plexus
pleural cavity-increases more volume of pleural fluid
superior vena cava
291
Q

what is a pancoasts tumour?

A

a tumour of the lung apex

292
Q

when a tumour has invaded bone (causing bone erosion) when will the patient complain the pain is worse?

A

pain worse at night

293
Q

where are common sites of metastases from a primary lung cancer?

A 
liver
brain-fits and headaches
bone
adrenals
skin
lung
294
Q

what hormone does a tumour mimic to cause hypercalcaemia?

A

parathyroid hormone

295
Q

what hormone does a tumour mimic to cause hyponatraemia (abnormally low Na levels)?

A

ADH

296
Q

what is the name of a syndrome which mimics myaesthenia gravis? (and is a paraneoplastic syndrome caused by an underlying -usually small cell- lung carcinoma)

A

Eaton Lambert syndrome

297
Q

why is there pain and tenderness of the long bones in hypertrophic pulmonary osteoarthropathy?

A

due to elevation of the periosteum away from the bones surface

298
Q

what is the pathophysiology of squamous carcinoma?

A

Most common cell type in europe

express nuclear antigen p63

arise from epithelial cells associated with production of Keratin. uncontrolled epithelial cell proliferation occurs

central necrosis which can caviate

cause obstruction lesions of bronchus with post obstruction infection

associated paraneoplastic syndrome: PTH like hormone secretion- hypercalacaemia

299
Q

What is the pathophysiology of Adenocarcinoma?

A

most common cell type in USA

express TTF1 mutations

Not associated with smoking

originate from mucus secreting glandular cells

cause peripheral lesions on CXR and CT

associated with HPOA

sub type: bronchioloalveolar carcinoma- spread of neoplastic cells along alveolar walls

300
Q

What is the pathophysiology of large cell carcinoma?

A

Poorly differentiated

high N:C

treated by surgical excision

301
Q

How do you manage Bronchial carcinomas?

A

Non small cell:

Surgery accessible: Surgery with adjuvant chemo and radiotherapy

not suitable then radiotherapy best form of treatment +/- chemotherapy

small cell: stage 1 may benefit from surgery otherwise:

limited-stage disease: this is confined to anatomical area and is present in approximately 30% of patients

treat with concurrent chemo and radiotherapy

Extensive disease: palliative care -carboplatin and etoposide/irinotecan

rule of thumb - small cell more chemo sensitive
non small cell more radiosensitive

chemo side effects:
nausea and vomiting

tiredness

bone marrow suppresion: opportunistic infection and anaemia

hair loss

pulmonary fibrosis

can have stereotactic ablative radiotherapy- less collateral damage then normal radiotherapy but requires 4D scanning

remember about small cell:only treated by chemotherapy but may become rapidly resistant to treatment.

302
Q

What is a malignant mesothelioma?

A

a tumour of mesothelial cells that usually occurs in the pleura and rarely in peritoneum

303
Q

What are the causes of malignant mesothelioma?

A

asbestos exposure

304
Q

what are the signs and symptoms of malignant mesothelioma?

A

Chest pain

SOB

weight loss

finger clubbing

recurring pleural effusion (main cause reason due to asbestos)

metastatic signs: lymphadenopathy, hepatomegaly, bone pain ,abdominal pain

305
Q

How do you diagnose malignant mesothelioma?

A

CXR/CT: Pleural thickening/effusion shows also peritoneal deposits

bloody pleural fluid

thoracoscopy- biopsy

pleural tap

306
Q

How do you manage malignant mesothelioma?

A

Pemetrexed + cisplatin can improve survival

pleurodesis and indwelling intra-pleural drain may help

surgery +/- chemo +/- radiotherapy

307
Q

What causes TB?

A

mycobacterium tuberculosis complex (MTb)

  1. mycobacterium tuberculosis
  2. mycobacterium bovis
  3. mycobacterium africanum
  4. mycobacterium mircroti

they are obligate aerobes

308
Q

What is the pathophysiology of TB?

A

Type IV hypersensitivity (granulomas with necrosis)

primary: first infection

inhaled organism is phagocytosed by alveolar macrophages in the hilar lymph nodes

antigen presentation to T lymphocytes leads to Type IV hypersensitivity reaction (delayed) - causes necrosis and formation of CASEATING granulomas

A Ghon focus forms - small calcified nodule on CXR normally found in periphery of mid zone of lung

secondary/latent: reactivation/reinfection of the disease

reactivates due to Decreased T cell function or reinfection at high dose

latent TB occurs due to persistent immune system containment (granuloma prevents bacteria spread). therefore infection without disease.

disease tends to initially remains localised often in apices of lung

can progress to spread by airways or bloodstream

309
Q

What are the tissue changes in TB?

A

primary:

Ghon focus forms

Large hilar nodes

secondary:

Fibrosing and caviating apical lesion

310
Q

What are the signs and symptoms of TB?

A

LATENT TB: asymptomatic

systemic: Fever, anorexia, weight loss, erythema nodosum, night sweats, malaise

pulmonary TB: productive cough, pleuritic pain, haemoptysis, mycetoma may form

laryngeal TB- hoarseness

GI TB: colicky abdominal pain and vomiting

SPINAL TB: local pain and bony tenderness

skin: red brown apple jelly nodules on skin- cutaneous TB

CNS TB: meningitis

risk of Fungal infection as opportunistic infection for immunosuppressed patients with TB

311
Q

What is miliary TB

A

TB becomes disseminated following passage into blood stream

causes widespread infection of lung

312
Q

What is the epidemiology of TB?

A

Majority of cases seen in Africa and Asia (china and India)

co infection of HIV in 12% of cases

313
Q

How do you diagnose TB?

A

CXR: Shows fibronodular opacities ,cavitation, calcification , effusion and lymphadenopathy

sputum sample:
NAAT- amplifies DNA and RNA in sputum via PCR or via transcription-mediated amplification (TMA). also used for drug resistant TB

ziehl Nelson staining- looks for “acid fast bacilli” all mycobacterium are acid fast

Tuberculin skin testing (Mantoux test)

tuberculin is injected- size of skin induration is used to determine positivity along with history of patient

DOES NOT EXCLUDE ACTIVE DIEASE OR DIAGNOSE needs clinical evaluation

interferon gamma release assays- diagnose exposure to TB by measuring release of interferon gamma from T cells reacting to TB antigen

DOES EXCLUDE ACTIVE DISEASE OR DIAGNOSE needs clinical evaluation

314
Q

How do you manage TB?

A

Antibiotics

(R) rifampicin- causes body secretions colour to be orange-red becareful with warfarin and oestrogens

(H) isoniazide-inhibits formation vit B6 which causes neuropathy therefore give with prophylactic Vit B6

(Z) pyrazinamide- causes hepatotoxicity

(E) ethambutol- causes colour blindness

give all four 2 month intensive courses if active disease

continue Rifampicin and isoniazide for 4 month continuation

latent 3 months of RH or 6 months of H

can use Anti TNF agents for reactivation TB

315
Q

What are the two main subtypes of influenza

A

influenza A

influenza B

316
Q

what is haemophilius influenzae?

A

a Gram-negative, aerobic, small bacilli

mainly a secondary invader

317
Q

What is the transmission of Influenza?

A

Rapid person to person spread by aerosolised droplets and contact

incubation- 1-4 days

318
Q

What are signs and symptoms of influenza?

A 
acute onset Fever, dry cough 
sore throat
headache
malaise
eye pain+/- photophobia
conjunctivitis
319
Q

what are the complications of influenza?

A

Primary influenzal pneumonia

secondary bacterial pneumonia- more common in infants, elderly and pregnant women

main cause in death of influenza epidemics

bronchitis

otitis media-infection of middle ear

encephalitis

320
Q

what is influenza in pregnancy associated with?

A

perinatal mortality

prematurity

smaller neonatal size

lower birth weight

321
Q

How do you diagnose influenza?

A

mainly clinical acute onset ,cough and fever major sign

Viral PCR

rapid antigen testing

clinical samples (throat swab, nasal swab, sputum)

322
Q

How do you manage influenza?

A
  1. uncomplicated influenza:

Symptomatic therapy- bed rest and paracetamol

  1. complicated influenza: risk of complications

antivirals (e.g. oseltamivir and zanamivir)

oseltamivir- PO or NG

zanamivir- inhaled

  1. prevention:
    post -exposure prophylaxis

annual vaccination

323
Q

what is antigenic drift?

what do they cause?

A

antigenic drift: small genetic changes during replication which can be accounted for in the annual vaccine

winter epidemics

324
Q

what is antigenic shift?

what do they cause?

A

process by which 2 or more different strains of virus combine to form a new subtype having a mixture of the surface antigen

pandemics

325
Q

which subtype is effected by antigenic shift?

A

influenza A

326
Q

what can also cause influenza pandemics?

A

non human influenza viruses which transfer to humans are novel

327
Q

what is the name of the H1N1 sub type of influenzae A?

A

swine flu

328
Q

who is the killed influenza vaccine given to?

A

adult patients at risks of complications
health care workers
children 6 months - 2 years at risk of complications
(annually)

329
Q

who is the live attenuated vaccine given to?

A

offered to
all children 2-5
all primary school children
(because live attenuated vaccine more effective in children 2-17 than killed vaccine)

330
Q

what is bronchiolitis?

A

inflammation of the small airways in the lungs due to viral infection

331
Q

what are the clinical presentations of bronchiolitis?

A

mainly in children (1-2 years old)

fever

coryza

cough

wheeze

severe cases:
grunting

hypoxia

intercostal in drawing

332
Q

what are the complications of bronchiolitis?

A

respiratory and cardiac failure

prematuririty

333
Q

what is the aetiology of bronchiolitis?

A

main cause is respiratory syncytial virus

also caused by metapneumovirus (discovered in 2001)

334
Q

how do you diagnose bronchiolitis?

A

PCR on throat or pernasal swabs

335
Q

how do you manage bronchioloitis?

A

supportive therapy

336
Q

What is acute bronchitis?

A

inflammation of bronchi caused by virus or bacteria infection

337
Q

what are the causes of acute bronchitus?

A

Mainly viral however secondary bacterial infection from strep pneumoniae or H influenzae is common

338
Q

what are the signs and symptoms of acute bronchitis?

A

previous URTI

productive cough

tight chestness

wheezing

SOB

339
Q

how do you manage acute bronchitis?

A

usually supportive

antibiotics if >65 and have COPD

amoxicilin and doxycycline

340
Q

What causes whooping cough (pertussis)?

A

bordatella perussis

341
Q

what are the signs and symptoms of whooping cough?

A

flu like symptoms

paroxysmal cough with inspiratory whoop

342
Q

how do you manage whooping cough

A

high contagious

antibiotics: erythromycin

343
Q

what causes acute epiglottitis?

A

haemophilius influenzae type B (Hib)

344
Q

what is the main age group affected by acute epiglottitis?

A

children (2-7)

345
Q

what are the signs and symptoms of acute epiglottis?

A

child is extremely ill- ( looks febrile, drooling)

high fever

severe airflow obstruction (stridor)

epigllottis is red and swollen

sore throat (especially in kids)

difficulty breathing- may lean forward

painful swallowing

hoarse voice (especially in kids)

346
Q

how do you diagnose acute epiglottis?

A

no usual mouth inspection :because if you push the tongue down the epiglottis will move to the top to cover the airways. if the epiglottis is inflamed it might stick to the top and not come down causing respiratory obstruction

‘X and V’ test for H.influenzae
(H. influenzae needs both factors X and V to grow)

culture-chocolate agar

347
Q

how do you manage acute epiglottitis?

A

Phone and call anaesthetist!

ITU and ceftriaxone (a 3rd generation cephlasporin)

prevention: Hib vaccination

348
Q

what are the common signs and symptoms of URTI?

A

cold: runny nose, nasal congestion
pharyngitis: dry/painful throat
sinusitis: nasal congestion, post nasal drip

clear chest!

349
Q

what are the signs and symptoms of acute laryngotracheobronchitis (croup)?

A

barking cough

stridor

hoarseness

very severe for children

350
Q

how do you manage acute laryngotracheobronchitits?

A

nebulised adrenaline- short term only used in emergencies

oral cortiocosteroids (dexamethasone)

oxygen and adequate fluids

351
Q

what is the final stage in tumour development before becoming malignant?

A

TIS- carcinoma in situ

352
Q

what is The initial stage in tumour development where cells gross appearance and histological findings are altered but there is no malignancy?

A

Squamous metaplasia

353
Q

what are the clinical features of lingular pneumonia?

A

pyrexia, dyspnoea and a productive cough.

On chest X-ray, the left heart border is obscured.

354
Q

Describe a granuloma.

A

A lung mass that may mimic a tumour, created in an attempt to wall off a pathogen or foreign body. Involves macrophages and may have a necrotic core.

355
Q

what is the alveolar macrophage also known as?

A

dust cell

356
Q

what is the role of CD4 + T cell?

A

Respond to pathogen peptides bound to HLA class II molecules. Activate other lymphocytes. Produce cytokines and influence phagocyte function. Immunoregulatory cells.

357
Q

what does Coxiella burnetti cause?

ii. what type of infection is it?

A

pneumonia, or a pyrexia of unknown origin (Q fever)

ii. zoonosis

358
Q

what are the characteristics of DI george syndrome?

A

child

multiple viral and bacterial infections,

recurrent oral candidiasis.

Clinically he has multiple facial features suggestive of a genetic cause to his condition.

investigations revealed a low T cell count and hypocalcaemia.

His cardiovascular system is abnormal.

359
Q

what causes flu like symptoms in children, secondary to another infection and peaks in incidence in winter epidemics?

A

metapneumovirus

360
Q

what is Chlamydia trachomatis

ii. how does it transmit?

A

sexually-transmitted infection that can cause infantile pneumonia

ii.by vertical transmission.

361
Q

what is serum tryptase?

A

mast cell degradation product that can be measured during an acute episode of anaphylaxis.

362
Q

what might lymphadenopathy look like?

A

enlarged lymph nodes- can be seen to affect the neck

hilar lymphadenopathy- enlargement of pulmonary lymph nodes

363
Q

What are the causes of pulmonary oedema?

A

cardiovascular - LVF

ARDS- any cause

fluid overload

neurogenic (head injury)

364
Q

What are the signs and symptoms of pulmonary oedema?

A
  1. SOB
  2. orthopnea
  3. Pink frothy sputum

sign:

  1. sitting up- difficult to breathe lying down
  2. Tachycardic
  3. tachypnoea
  4. raised JVP
  5. fine lung crackles
  6. wheeze (cardiac asthma)
  7. gallop rhythm
365
Q

How do you diagnose pulmonary oedema?

A

CXR:
cardiomegaly

signs of bilateral shadowing, effusions (can be seen at costophrenic angles) - bat wings

Kerley B lines ( septal linear opacities)

fluid in lung fissures

ECG: sign of MI and dysrhtymias

U&E : troponin

consider Echo

366
Q

How do you manage pulmonary oedema?

A

Monitor progress (BP, pulse , RR, JVP and cyanosis)

Daily weights

repeat CXR

  1. sit patient upright
  2. high flow oxygen
  3. Treat any arrhythimias
  4. give diamorphine IV
  5. then furosemide IV (40-80mg)
  6. GTN spray 2 puffs (don’t give if systolic BP <90mmHg)

once stable and improving

  1. oral furosemide or bumetanide
  2. If large dose of loop diuretic consider adding thiazide
  3. ace inhibitor if LVEF <40% also can consider beta blocker and spironolactone if LVEF <35%

if worsening

continue dose of furosemide IV (40-80mg)

consider CPAP

367
Q

what is churg-strauss syndrome?

A

Eosinophilic granulomatosis with polyangiitis- causes inflammation of blood vessels

368
Q

what are the signs and symptoms of churg-strauss?

A

triad:
1. adult onset asthma
2. eoinophilia
3. vasculitis

369
Q

How do you diagnose Churg strauss syndrome?

A

CXR: unusual pattern of changing infiltrates, some of which were bilateral, and changed transiently.

Blood: eosinophilia and inflammatory markers were raised. Also can be p-ANCA positive

biopsy of lung tissue: eosinophilic infiltrate and granuloma.

370
Q

How do you manage churg strauss syndromes?

A

steroids

371
Q

What are the signs and symptoms of Lupus (SLE)

A
  1. remitting and relapsing illness

general :

malaise

fatigue

myalgia

fever

lymphadenopathy

weight loss

red rash

oral/nasal ulcers

alopecia

PE

pleural rub

pericardial pain

372
Q

How do you diagnose Lupus?

A
  1. Immunology:

ANA +ve

dsDNA +ve (60% of cases)

ENA +VE

therefore

  1. Anti-dsDNA antibody titres
  2. Complement : low C3 and C4
  3. eSR

FBCs, U&E,LFTs and CRP usually normal

373
Q

A newborn has a diaphragmatic hernia and associated dextrocardia. His repair goes well, but his pulmonary abnormality is persisting what does this suggest?

A

pulmonary hypoplasia

374
Q

which babies are most likely to suffer from newborn respiratory distress syndrome?

A

premature babies

375
Q

what does An autoantibody screen reveals anti-CCP antibodies at 1:640 and a raised ESR and CRP suggest?

A

rheumatoid arthritis

376
Q

what are the causes of pleurisy/pleuritis?

A
  1. pneumonia
  2. pulmonary infarct
  3. carcinoma

rarer causes

  1. lupus
  2. rheumatoid arthritis
377
Q

what are the signs and symptoms of pleurisy?

A

localised sharp pleuritic pain-

worse on:

  1. deep inspiration
  2. coughing
  3. twisting or bending movements
378
Q

what is good pastures syndrome?

A

rare autoimmune illness with production against the glomerular basement membrane

379
Q

what are the signs and symptoms of good pastures’ disease?

A

pulmonary haemorrhage

glomerulonephritis

haemoptysis

SOB

380
Q

How do you diagnose Good pasture’s disease?

A

CXR: shows pulmonary infiltrates

renal biopsy- crescentic glomerulonephrititis

blood: anti-GBM antibodies

381
Q

what can lisinopril cause?

A

dry cough - incredibly irritating

drug used for hypertension

382
Q

What is chemical pneumonitis?

A

inflammation of the lungs due to exposure from chemical inhalation

secondary to formaldehyde exposure

common in people working in body embalmer, resin , leather and rubber industries

383
Q

The visceral pleura should be penetrated during chest drain insertion true or false?

A

false

384
Q

What is the most common cause of exudative ascites?

A

Malignancy

Infection

385
Q

What factors are associated with pneumocystisis?

A

IVDU

progressive Dysopnea

tachyopnea

Batwing cxr

386
Q

What are the causes of pulmonary fibrosis?

A

Drugs: Bleomycin, azathioprine

pneumoconiosis

occupational lung disease

387
Q

Which type of bronchial carcinoma can Syndrome of inappropriate antidiuretic secretion (SIADH)

A

small cell

SIADH - retains more water retention but absorbs less sodium

388
Q

How do you diagnose granulomatosis with polyangitis? (GPA)

A

positive ANCA antibodies

389
Q

How does hypoxia cause RV hypertrophy?

A

Causes smooth muscle constriction.

this increases pulmonary vascular resistance and hypertension

this increases RV afterload leading to hypertrophy

390
Q

what is usually obscured in left upper lobe pneumonia?

A

Left heart border

391
Q

what characteristics does Diphtheria have?

A 
pseudomembrane affected (swollen throat)
Been to tropics

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