clinical Flashcards
1
Q
What is breathlessness also known as?
A
dyspnoea
2
Q
what might be the cause of breathlessness if its severity alters at different times in the day?
A
Asthma.
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.
4
Q
What might be the cause of paroxysmal nocturnal dyspnoea?
(waking up breathless in the night?
A
Pulmonary oedema or asthma.
5
Q
What are non respiratory causes of breathlessness?
A
- anaemia
- Heart failure
- cardiac arrhythmias
- Anxiety
- diabetic ketoacidosis
6
Q
What are the four classes of sputum?
A
- Mucoid - clear,grey or white
- Serous-watery or frothy
- Mucopurulent - yellowish tinge
- Purulent - dark green/yellow.
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.
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.
9
Q
What are non respiratory causes of coughing?
A
- Gastroesophageal reflux
2. Postnalsal drip secondary sinusitis or drug induced.
10
Q
What is the difference between haemoptysis and haematemesis?
A
Haemoptysis - coughing up of blood
Haematemesis - vomiting of blood.
11
Q
What are respiratory causes of haemoptysis?
A
- bronchial carcinoma
- Pulmonary embolism— caused by DVT maybe
- TB
- Pneumonia
- Bronchiectasis
- Acute/chronic bronchitis
- Pulmonary vasculitis.
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.
13
Q
Commonest respiratory causes of wheeze?
A
- COPD
- Asthma
- Pulmonary oedema
14
Q
What is stridor?
What could be a cause ?
A
- Audible inspiratory noise- indicates partial obstruction of the upper,large airways.
ii. Tumour
epiglottitis
inhalation of foreign body.
15
Q
What are the characteristics of pleural pain?
What are its causes?
A
- Sharp stabbing pain.
Pulmonary emboluus or infection.
16
Q
What are the main causes of chest pain respiratory and non respiratory?
A
- Tietze’s syndrome - costochondral junction.
- Rib fracture or tumour - Bone
- Herpes zoster, pancoast tumour - Nerves
- Acid reflux - oesophagus
- MI,aortic dissection and aortic aneurysm - heart and vessels
- Pneumothorax and Pulomanry embolism (PE)- pleura
- Strain from coughing - muscle.
17
Q
What could be a cause for unintentional weight loss?
A
- Carcinoma
- TB
- severe emphysema
18
Q
what are the causes of ankle swelling?
A
- COPD
2. Cor pulmonale
19
Q
What can childhood infections such as pneumonia lead to?
A
Bronchiectasis
20
Q
How can you calculate number of pack years?
A
(Packs smoked per day) x (years as a smoker)
21
Q
What is the normal respiratory rate?
A
12-20 breaths per minute
22
Q
What is the term used to describe a breath rate higher than 20 breaths per minute?
A
Tachypnoea
23
Q
What is the term used to describe a breath rate lower than 12 breaths per minute?
A
Bradypnoea
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
25
What is Cheyne-Stokes respiration?
ii. What are its cause?
Increased rate and volume of respiration by periods of apnoea.
ii. Terminal disease
Increasesd intercranial pressure
26
What causes prolongation of expiration?
air flow limitation.
27
What causes pursed-lip breathing?
Air trapping.
28
Give examples of side effects of long term use of steroids.
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
29
What are the respiratory causes for clubbing?
1. Congenital illness
2. cystic fibrosis
3. bronchial caricnoma
4. mesothelioma
5. pulmonary metastases
6. Empyema
7. Bronchiectasis
8. Lung fibrosis
30
COPD is cause of clubbing true or false?
false
31
Besides measuring pulse rate, what can the radial pulse be also used to calculate?
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.
32
Where can the JVP be visible from?
ii. How can you make it be more visible?
Visible above the clavicle in between the two heads of the sternocleidomastoid.
ii. Can be accentuated by the hepatojugular reflux.
33
How can you measure the JVP?
ii. What would class it as being raised?
measure from the sternal notch
ii If it is greater than >4 cm
34
Define what is Kyphosis
Increased curvature of the spine.
35
Define what scoliosis?
Increased lateral curvature of the spine.
36
What might you look for in the mouth of a patient in a respiratory exam?
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.
37
What are the characteristics of Horner syndrome?
ii. What might horner syndrome mean?
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.
38
Where is the apex beat found?
ii. What respiratory disease might be the cause it is displaced?
Fifth intercostal line on the midclavicular line.
ii. Pulmonary fibrosis
Bronchiectasis
Pleural effusions
Pneumothoraces
39
What is :
i Pectus excavatum?
ii. Pectus carinatum
iii. Barrel chest? whats its cause?
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.
40
What could be the causes for hyperesonant percussion?
1. Pneumothorax
| 2. Emphysema with large bullae (fluid sac)
41
What could be the causes for dull percussion?
1. Consoldiation
2. Fibrosis
3. Pleural thickening
4. Collapse
5. Infection
42
What could be the causes for stony dull percussion?
Pleural effusion.
43
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.
i. None
ii. Normal
iii. Dull
IV. Increased
v. Crackles
VI. Increased
44
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.
i. None
ii. Normal
iii. Hyperesonant
IV. decreased
V. Click (occasional)
VI. Decreased
45
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.
i. None
ii. Decreased
iii. Stony dull
IV. decreased
V. Rub (occasional)
Vi. decreased.
46
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.
i. Towards
ii. Decreased
iii. Dull
iv. decreased
v. none
vi. decreased.
47
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.
i. None
ii. Decreased
iii. Dull
iv. decreased
v. none
vi. decreased.
48
Describe what a bronchoscopy is?
ii. What are the two types?
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
49
What is a transbronchial biopsy?
ii. What are the dangers of using it?
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.
50
What is sleep apnea?
ii. What is it associated with?
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.
51
What is a Endobronchial ultrasound?
ii. What is the role of this?
Probe which is placed down a bronchoscope.
Used for real time visualisation of deeper structures through the bronchial walls such as the lymph nodes.
52
What is a lung biopsy?
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
53
What are the dangers of percutaneous fine-needle aspiration?
Complications may lead to pneumothorax post biopsy.
54
What is the role of a Peak flow meter?
It measures the maximum expiratory rate in the first 10 milliseconds of expiration.
55
What should the patient be instructed when using a peak flow meter?
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.
56
What is the normal PEFR range in a healthy adult?
400-650 L/min
57
Suggest some conditions which would lead to a reduced PEFR.
1. Asthma
2. COPD
3. Upper airway tumours
4. Expiratory muscle weakness.
58
Why is PEFR not a good measure of airflow limitation?
Because it only measures initial expiration.
59
What is the forced expiratory volume in 1 second (FEV1)
Volume of air expelled in the first second of a forced expiration, starting from full inspiration.
60
What is the FVC?
A measure of total lung volume exhaled.
61
What is the FEV1:FVC ratio?
ii. What is the normal value?
Is a measure of airway limitation and allows to differentiate between restrictive and obstructive lung disease.
ii. FEV1 is 80% the value of FVC.
62
How can you differentiate between restrictive and obstructive respiratory disease using the FEV1:FVC ratio?
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%)
63
what does stridor or gurgling suggest?
ii. What should you do?
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.
64
What is respiratory failure?
ii. What is the main characteristic of respiratory failure?
Defined as a failure to maintain adequate gas exchange.
ii. PaO2 < 8 kPa - hypoxia
65
What are the types of respiratory failure?
What are the differences?
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
66
What are the causes of Type 1 respiratory failure?
hypoventilation with V/Q mismatch
Severe acute asthma
Pneumonia
Pulmonary embolism
Pulmonary oedema
ARDS
pulmonary fibrosis
67
What are the causes of Type 2 respiratory failure?
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
2. Reduced respiratory drive
sedative drugs
CNS trauma
3. Neuromuscular
Cervical cord lesions
Paralysis of diaphragm
Myasthenia gravis
Guillain- Barre syndrome
4. thoracic wall disease- kyphoscoliosis
68
What are the signs and symptoms of respiratory failure?
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
69
How do you diagnose respiratory failure?
Blood tests -FBC, U&E, CRP, ABG
blood cultures
CXR
sputum culture
Bedside spirometry testing- for COPD and Guillan Barre syndrome
70
How do you manage Respiratory failure?
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
71
What would over-oxygenation lead to with type 2 respiratory failure?
leads to suppression of ventilation and partial pressure of CO2 may rise than fall.
72
What would a rise of PaCO2 cause?
rise in respiratory acidosis.
73
What is the Oxygen saturation levels with those having oxygen therapy?
88-92%
74
What is the normal range of oxygen saturation in healthy subjects?
94-98%
75
What is the flow of rate and estimated percentage of oxygen delivered in:
Nasal cannulae
simple face mask
venturi mask
Nonrebreather
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%
76
What is CPAP
what is its role?
continuos positive airway pressure
Provides oxygen delivery added fixture positive pressure throughout the respiratory cycle. Mainly used for Type 1 failure and hypoxaemia
77
What is the range of the pressure delivered?
5-15 cm H20.
78
When would you use noninvasive ventilation?
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.
79
When would you use invasive ventilation?
Facial trauma or airway obstruction
Inability to protect the upper airway
Pneumothorax.
80
What is Anaphylaxis?
Serious allergic reaction that is potentially life threatening.
81
What type of reaction is anaphylaxis?
ii. What is it mediated by?
Acute type 1 immune reaction
ii. It is mediated by IgE and mast cells.
82
What are the clinical symptoms of anaphylaxis?
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.
83
How do you manage anaphylaxis?
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
84
Why is foreign body aspiration bad?
Causes airway obstruction especially bad if blocks trachea or larynx.
85
What are the clinical symptoms of foreign body aspiration?
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.
86
What investigations can be carried out to detect foreign bodies in the airway?
Blood tests- may demonstrate inflammatory response
Chest X-ray
Bronchoscopy
87
How can you remove the object?
Bronchoscopy
encourage coughing
Heimleich manouvre ( abdominal thrusts and back slaps).
88
What is a Rhinitis?
Inflammation of mucosal membrane lining the nose.
89
Give examples of viruses which cause the common cold.
Rhinovirus
Coronavirus
Adenovirus
Parainfluenza virus
respiratory synctial virus
90
What are the symptoms of common cold?
Nasal obstruction
Rhinorrhoea (runny nose)
Sneezing
91
What is are pathological causes of the common cold?
Acute inflammation with oedema
glandular hyper-secretion
Loss of surface epithelium.
92
what are the causes of chronic rhinitis ?
An acute inflammatory episode.
Poor drainage of sinus
nasal obstruction by polyps
93
What are the causes of allergic rhinits?
IGE mediated response to common environmental allergens.
94
What is the pathological physiology for Type 1 IGE-mediated hypersensitivity reaction?
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.
95
What is pneumonia?
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
96
What types of pneumonia are there?
Community acquired pneumonia (sub type atypical community acquired pneumonia)
Hospital acquired
aspiration
pneumonia in immunocompromised patients
97
What are the causes of community acquired pneumonia?
| CAP
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
98
What is hospital acquired pneumonia defined as?
Pneumonia which has developed >2 days after admission to hospitals
99
What are the common causes of Hospital acquired pneumonia? (HAP)
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
100
What is aspiration pneumonia?
acute aspirations of gastric contents into the lungs. Most common sites of this are right middle lobe or posterior segments of right lower lobe.
101
What can aspiration pneumonia cause?
Lung abscesses
102
Which groups of people are at risk of aspiration pneumonia?
Patients with:
1. Strokes
2. Bulbar palsy
3. oesophageal disease (achalasia,reflux)
4. intoxicated
(look for impaired swallowing or alcoholic)
103
What is the cause of aspiration pneumonia?
anaerobes
104
What are the causes of pneumonia in immunocompromised patients?
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
105
What are the common signs and symptoms of pneumonia?
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
106
How do you diagnose pneumonia?
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
107
How do you assess the severity of pneumonia?
CURB-65
108
when would you use CRB-65?
used in the community
when serum urea level is not usually available
109
What is CURB-65?
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
110
How do you manage CAP?
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
111
How do you manage HAP?
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
112
How do you manage aspiration pneumonia?
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
113
What are the main complications of Pneumonia?
1. Respiratory failure
2. Hypotension
3. Atrial fibrilation- common in elderly
4. Pleural effusion
5. Empyema
6. Lung abscess
114
What type of chlamydia which causes pneumonia is associated with pet birds?
ii. How is it diagnosed and treated?
Chlamydophilila psittaci
chladmydophila serology
treat with doxycycline or clarithromycin
115
How do you treat Pneumocystis jirovercii?
Co trimaoxazole
116
What do Mycoplasma pneumoniae, chlaymida psittici,coxeilla and legionella all respond to?
Clarithromycin
117
What is empyema?
Pus in the pleural space
also called pyothorax
118
when should empyema be suspected?
if a patient with a resolving pneumonia develops recurring fever
119
what are the symptoms of empyema?
CXR indicates pleural effusion
aspirated pleural fluid is typically yellow and turbid
120
how do you manage empyema?
Drained using a chest drain inserted under radiological guidance
adhesions and loculation make this difficult
121
What is a lung abscess?
focus of infection with a fibrous wall
formation of cavity area of localised suppurative (pus causing) infection within the lung
pus formed in cavities
122
What are the causes of lung abcesses?
inadequate treated pneumonia
aspiration
bronchial obstruction
pulmonary infarction
septic emboli- septicaemia and right heart endocarditis
misplaced NG tube
123
What are the sign and symptoms of lung abscess?
Swinging fever
cough
purulent sputum
pleuritic pain
empyema can form
look for clubbing and anaemia
124
How do you diagnose lung abscess?
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
125
How do you manage lung abscess?
antibiotics
postural drainage
may require surgical excision
126
what is bronchopneumonia?
infection starting in airways and spreading to adjacent alveolar lung
127
what can be an underlying cause of bronchopneumonia?
COPD
cardiac failure
complication of viral infection
aspiration of gastric contents
128
what is lobar pneumonia?
confluent consolidation involving a complete lung lobe
129
What is COPD?
chronic obstructive pulmonary disease- common progressive disorder characterised by airway obstruction with little or no reveresibility
130
What are the two main conditions that make up COPD?
emphesyma
chronic bronchitis
131
What is the epidemiology are the risk factors of COPD?
>45 years old
```
smoking ( passive or active)
or pollution (dust and cilica)
```
chronic dyspnoea
sputum production
132
What is chronic bronchitis?
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)
133
What is emphysema?
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
134
What is the pathophysiology of COPD?
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.
135
What should be looked into with a patient who is younger than 45 years old and has empheysma?
alpha one anti-trypsin deficiency
136
What is alpha one anti-trypsin?
ii. what inhibits it?
protease inhibitor produced in the liver
inhibits proteolytic enzymes such as neutrophil elastase.
ii. smoking
137
What are the signs and symptoms of COPD?
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.
138
is emphysema reversible?
no
139
is chronic bronchitis reversible?
partially- bronchoconstriction can be reversed
140
What are the presentations of a pink puffer?
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
141
What are the presentations of Blue bloaters?
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
142
How do you diagnose COPD?
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
143
How do you treat COPD?
General
1. Smoking cessation
2. Flu Jab to prevent infection
3. Exercise and diet advice
4. 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
1. LAMA- tiotropium,aclidinium (selective m3)
2. LABA
3. LAMA/LABA/ICS combo
4. LABA-ICS combo- salmeterol/fluticasone
remember LAMA - muscarinic antagonist
LABA - beta agonists
5. PDE4 Inhibitor-e.g. roflumilast- never alone used for severe COPD
6. mucolytic medicine
7. antibiotics-e.g. azithromycin never alone
a mucolytic - may help with chronic productive cough e.g. carbocysteine
144
What are acute exacerbations of COPD?
acute worsening of COPD symptoms
145
What are the signs and symptoms of acute exacerbations of COPD?
Increasing cough/wheeze/SOB
decreased exercise capacity
146
How do you diagnose Acute exacerbation of COPD?
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
147
How do you manage Acute exacerbation of COPD?
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
148
where is centriacinar emphysema?
distention and damage of lung tissue is concentrated around the respiratory bronchioles
149
What is pan-acinar emphysema
ii. what is it associated with
distention and damage affect whole lung (includes alveoli)
ii. alpha 1 antitrypsin deficiency
150
what is the difference between asthma and COPD in terms of onset?
Asthma -earlier onset (generally)
COPD- late onset
151
What is the difference between asthma and COPD in terms of smoking?
asthma not related to smoking
COPD smoking history is a major cause
152
What is the difference between asthma and COPD in terms of allergies?
asthma- can be allergic
| COPD- always non-allergic
153
compare asthma and COPD in terms of duration of symptoms?
asthma- intermittent symptoms
| COPD- chronic continual symtpoms
154
compare asthma and COPD in terms of disease progression?
asthma- not progressive
| COPD- progressive
155
compare asthma and COPD in terms of cough?
asthma- dry cough
| COPD- productive cough
156
compare asthma and COPD in terms of main immune cell mediator?
asthma- eosinophils
| COPD- neutrophils
157
compare asthma and COPD in terms of daily variability?
asthma- diurnal variability
| COPD- no variability
158
compare asthma and COPD in terms of corticosteroid and bronchodilator response?
asthma- good response in both corticosteroid and bronchodilator response
COPD- poor corticosteroid and bronchodilator response
159
compare asthma and COPD in terms of FVC and TLCO?
asthma- FVC and TLCO preserved
| COPD- reduced FVC and TLCO(DLCO)
160
compare asthma and COPD in terms of gas exchange?
asthma- normal gas exchange
| COPD- impaired gas exchange
161
What are the symptoms of Asthma?
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
What are the three main characteristics of asthma?
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
What are the environmental triggers which cause Asthma?
1. Cold air
2. allergens (house, dust mite, pollen fur)
3. infection
4. smoking
5. pollution
6. drugs (NSAIDs, Beta blockers)
164
What should you ask when taking a history for asthma?
1.Ask about precipitants ( enviromental triggers)
2. Diurnal variation - Worse in morning.
Disturbed sleep?- sign of severe asthma
3. exercise- how much can they do?
4. Atopic?- family history of allergies, eczema, hayfever
5. home- pets, carpet, feather pillows?,smokers?
6. occupation- do symptoms get better on weekends or holidays? any potential triggers e.g. animal handlers
7. Days per week off school/work due to asthma?
165
what type of pathway do asthmatic pathways express?
Th2 pattern of cytokine expression
166
what is childhood onset- asthma often accompanied with?
eczema- atopic dermatitis
167
How do you diagnose asthma?
1.spirometry : shows obstructive defect-FEV1/FVC below 75%
also shows >15% improvement of FEV1 following salbutamol
2. FENO (increased)
3. 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
How do you manage chronic asthma?
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
What types of asthma are there?
1. intermittent
2. mild persistent
3. moderate persistent
4. severe
170
What is the presentation of acute severe asthma?
Acute breathlessness and wheeze
unable to complete sentences
171
How do you diagnose acute severe asthma?
PEF- may be too ill
ABG if sats are lower than 92%
life threatening features of asthma
CXR ( if pneumothorax or infection suspected)
172
How do you assess severity of acute asthmatic attack?
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
How do you manage acute asthmatic attacks?
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
whats the difference between extrinsic and intrinsic asthma?
extrinsic- allergen caused
intrinsic- non allergen caused
175
what is atopic asthma?
allergic asthma
176
what is theophylline?
A methylxanthine drug with bronchodilator and anti-inflammatory action. Has many side effects and drug interactions.
177
what is Fexofenadine?
A competitive H1 receptor antagonist used to treat allergic rhinitis.
178
what is Ipratropium?
A short acting drug that blocks acetylcholine receptors non-selectively. Can be delivered intranasally to treat rhinorrhoea.
SABA
179
what is tiotropium?
An anticholinergic drug, selective for M3 receptors with a long half life.
180
what is Monteleukast?
A cysteinyl leukotriene receptor antagonist used to treat asthma and allergice rhinitis.
181
what is Beclometasone?
An inhaled corticosteroid. Used in combination with a beta-2 adrenoceptor agonist, particularly in frequent exacerbations of COPD.
182
what is Sodium cromoglicate?
A drug that acts as a mast cell stabiliser, used in asthma and allergic rhinitis.
183
What is ARDS?
Acute respiratory distress syndrome- lung damage and release of inflammatory mediators cause increased capillary permeability and non-cardiogenic Pulmonary oedema.
184
What are the causes of ARDS?
Respiratory causes: Pneumonia, Gastric aspiration, inhalation, injury, contusion
General: shock, septicaemia, haemorrhage, multiple transfusion, Pancreatitis, acute liver failure, pregnancy events (eclampsia), drugs
185
What are the signs and symptoms of ARDS?
```
Cyanosis
tachypnoea
tachycardia
peripheral vasodilation
bilateral fine inspiratory crackles
```
186
How do you diagnose ARDS?
Blood:FBC U&E,LFT,CRP, clotting
blood cultures,ABG
CXR- bilateral pulmonary infiltrates
PCWP- use pulmonary artery catherter
187
what is the diagnostic criteria of ARDS?
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
How do you manage ARDS?
1. admit to ITU and give supportive therapy- treat underlying cause
Respiratory support- early ARDS may use CPAP otherwise mechanical ventilation required
2. Circulatory support- haemodynamic monitoring
189
What is the normal pH of blood?
7.35-7.45
190
What is it called when pH falls below normal range?
acidosis
191
What is it called when pH rises above normal range?
alkalosis
192
Explain the values of:
1. metabolic acidosis
2. respiratory acidosis
3. metabolic alkalosis
4. respiratory alkalosis
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
What is a pulmonary embolism
Obstruction of the pulmonary artery or one of its branches by an embolus.
194
What are the causes of Pulmonary embolism?
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
what are the main factors which cause DVT?
| Virchows triad
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
2. Hypercoagulation- altered amount of clotting factors promote haemostaisis
causes include: thrombophilia (genetic), surgery (physical damage, contraceptive pills ( increase levels of clotting factors)
3. damage to endothelial lining-
caused by infection or toxins (smoking)
malignancy also a factor
196
What are the signs and symptoms of PE?
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
What are the clinical features of DVT?
warm/tender, swelling calf
mild fever
pitting oedema
198
How do you diagnose PE?
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
How do you manage PE?
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
what is unprovoked PE?
patient with no known provoking risk factors
201
what is Pleural effusion?
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
what is a haemothorax?
blood in the pleural space
203
what is a chylothorax?
lymph fluid containing fat in the pleural space
204
What are the causes of pleural effusion?
Transudates-
1. mainly due to increased venous pressure
cardiac failure
constrictive pericarditis
fluid overload
2. hypoprotienaemia
Cirrhosis
nephrotic syndrome
malabsorption
3.Meigs syndrome
Exudates
1. increased leakiness of pleural capillaries
infection (pneumonia, TB)
inflammation (rheumatoid arthritis)
malignancy ( carcinomas)
205
what are the signs and symptoms of pleural effusion
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
How do you diagnose Pleura effusion?
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
How do you manage pleural effusion?
treat underlying cause
drainage- if symptomatic
pleurodesis with talc if effusions are recurrent. best for malignant effusions. empyema are best chest drained.
208
How do you diagnose DVT?
1. ultrasound doppler leg scan (1st line)
| 2. CT scan for ileo femoral veins, IVC and pelvis
209
What is obstructive sleep apnoea?
intermittent closure of the pharyngeal airway causing apnoeic episodes during sleep
210
what are the risk factors of sleep apnoea?
enlarged adenoids
obesity
middle aged man
retrognathia
hypothyroidism
stroke,MS
drugs- opiates,alcohol
post op period after anaesthesia
211
what are the signs and symptoms of sleep apnoea?
Loud snoring
excessive daytime sleeping
poor quality sleep
morning headache
reduced cognitive performance
212
what are the complications associated with sleep apnoea?
1. pulmonary hypertension
2. type 2 resp failure (acute type II resp failure is compensated respiratory acidosis)
3. increased risk of hypertension
213
how do you diagnose sleep apnoea?
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
how do you manage sleep apnoea?
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
What is cor pulmonale?
right heart failure caused by chronic pulmonary arterial hypertension
216
What are the causes of cor pulmonale
COPD
bronchiestasis
pulmonary fibrosis
severe chronic asthma
pulmonary emboli
kyphosis
scoliosis
MND
sleep apnoea
217
What are the signs and symptoms of cor pulmonale
SOB
fatigue
syncope
signs:
cyanosis
tachycardia
raised JVP
hepatomegaly
oedema
dilated chest veins
218
How do you diagnose Cor pulmonale
Blood: FBC- Hb and haematocrit increased
ABG- Hypoxia
CXR- enlarged right atrium and ventricle
ECG- right axis deviation, right ventricular hypertrophy
219
How do you manage cor pulmonale?
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
What is Sarcoidosis?
A multi system Granulomatous (type IV hypersensitivity) disease of unknown cause.
non- caseating granulomas
221
What is the epidemiology of sarcoidosis?
20-40yrs old
women
afro-carribean are affected more frequently
222
what are the signs and symptoms of sarcoidosis?
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
How do you diagnose sarcoidosis?
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
How do you manage sarcoidosis?
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
What are the common organs involved in sarcoidosis?
Lungs, lymph nodes, joints, skin, liver, eyes
Less common- kidneys, brain , nerves, heart
226
What is a interstitial lung disease?
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
What types of interstitial lung disease are there?
acute
episodic
chronic- part of systemic disease, known cause ,idiopathic (three types)
228
What are the signs and symptoms of Interstitial Lung diease?
SOB
dry cough
abnormal breath sounds
abnormal CXR- shows fibrotic shadowing
restrictive pulmonary spirometry with low DLCO
229
What are the pathological features ILD?
Fibrosis and remodelling of the interstitium
chronic inflammation
Hyperplasia of type II epithelial cells
230
Give examples of ILD.
1.Systemic disorders:
Sarcoidosis
Rheumatoid arthritis
Systemic sclerosis
UC
autoimmune thyroid disease
2. 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
What examples of Interstitial lung disease cause upper zone fibrotic shadowing on CXR?
TB
Progressive massive fibrosis
radiotherapy
232
What examples of ILD cause mid zone fibrotic shadowing on CXR?
Sarcoidosis
histoplasmosis
233
What examples of ILD cause lower zone fibrotic shadowing on CXR?
Idiopathic pulmonary fibrosis
asbestosis
234
What is extrinsic allergic alveolitis?
Repetitive inhalation of allergens causes a type III hypersensitivity reaction (immune complex desposition)
235
what are the causes of EAA?
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
What are the signs and symptoms of EAA?
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
How do you diagnose EAA?
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
How do you manage EAA?
Acute: remove allergen and give O2 and oral prednisolone
chronic : allergen avoidance or wear face mask
long term steroids
239
What is idiopathic pulmonary fibrosis?
most common cause of interstitial lung disease
Idiopathic interstitial pneumonia associated with Inflammatory cell infiltrate and pulmonary fibrosis
240
What are the signs and symptoms of IPF?
Think 3 C's (cough, clubbing and cyanosis)
Dry cough , SOB, weight loss, arthralgia
signs: cyanosis, finger clubbing, fine end-inspiratory crackles
241
How do you diagnose IPF?
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
How do you manage IPF?
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
how is fibrosis shown on CXR?
honey-combing
244
what is pneumoconiosis?
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
What is coal worker's pneumoconiosis?
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
What are the signs and symptoms of coal worker pneumoconiosis?
Usually asymptomatic
can have co existing chronic bronchitis
247
How do you diagnose CWP?
CXR: many round opacities especially in upper zone (nodular shadowing)
248
How do you manage CWP?
avoid exposure to coal dust
treat chronic bronchitis
claim compensation!
249
What is progressive massive fibrosis?
upper mid zone fibrosis forme due to progression of CWP
250
What are the signs and symptoms of progressive massive fibrosis?
worsening SOB
fibrosis -- then cor pulmonae
251
How do you diagnose PMF?
CXR : shows bilateral upper mid zone fibrotic masses develop from periphery
spirometry-restrictive pattern
252
How do you manage PMF?
avoid exposure to coal dust
253
What is caplan's syndrome?
rheumatoid pneumoconosis (pulmonary nodules)
254
What is silicosis caused by?
inhalation of silica particles which are fibrogenic
jobs included are: metal mining, stone quarrying, sand blasting and pottery manufacture
255
what are the signs and symptoms of silicosis?
progressive SOB
256
How do you diagnose silicosis?
```
CXR-
shows fibrosis (nodular pattterns in upper and mid zones
```
shows egg-shell calcification of hilar nodes
spirometry: restrictive ventilatory defect
257
How do you manage silicosis?
avoid exposure to silica
258
What is asbestosis caused by?
inhalation of asbestos fibres
asbestos is found in fire proofing, electrical wire insulation and roofing
259
What are the signs and symptoms of asbestosis?
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
what are the 2 types of asbestos fibres?
serpentine (curved)- safer cant get stuck in large airways
straight
261
what type of lung biopsies can you take?
```
transbronchial biopsy (during bronchoscopy)
thoracoscopic biopsy (minor thoracic surgery)
```
262
what is the formation of pleural disease?
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
What is pneumothorax?
air in the pleural cavity which can lead to lung collapsing.
264
What is spontaneous pneumothorax?
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
what are the other causes of pneumothorax?
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
What are the signs and symptoms of Pneumothorax?
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
How do you diagnose pneumothorax?
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
How do you manage pneumothorax?
<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
What is tension pneumothorax?
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
What will happen if tension pneumothorax is not fixed?
cardiorespiratory arrest
271
why is tension pneumothorax so serious?
as the pressure build up cause the mediastinum to push over into the contralateral hemithorax kinking and compressing the great veins
272
what are the signs and symptoms of Tension pneumothorax?
ii. how do you differentiate between simple and tension pneumothorax
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
How do you manage tension pneumothorax?
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
What is bronchiectasis?
widening of the bronchi or their branches
275
what is the pathophysiology of bronchiectasis?
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
what are the causes of bronchiectasis?
Congenital : CF, young's syndrome , Kartagener's syndrome
Post-infection: Measles, Bronchilitits, pneumonia, TB, HIV
other: Bronchial obstruction, UC, idiopathic and rheumatoid arthiritis
277
What are the signs and symptoms of bronchiectasis?
Symptoms : persistent cough, persistent purulent sputum , intermittent haemoptysis
signs: Finger clubbing, inspiratory crepitations, wheeze coarse crackles
278
How do you diagnose bronciectasis?
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
How do you manage bronchiectasis?
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
What is cystic fibrosis
autosomal recessive condition caused by mutations in the CFTR gene on chromosome 7
1:25
281
what is the pathophysiology of cystic fibrosis?
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
what are the signs and symptoms of cystic fibrosis?
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
How do you diagnose cystic fibrosis?
Sweat test: sodium and chloride >60mmol/L
genetic screening
culture-pseudomonas aeruginosa can be present
284
How do you manage CF?
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
what is bronchial carcinoma?
ii. what are its main risk factors?
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
what is the histology of bronchial carcinoma?
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
What are the signs and symptoms of Bronchial carcinoma?
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
What are the complications of bronchial carcinoma?
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
2. non metastatic: paraneoplastic
finger clubbing
hypertrophic pulmonary oesteoarthropathy (HPOA)
weight loss
hypercalcaemia- causes headaches, constipation and thirst
SIADH
289
how do you diagnose bronchial carcinoma?
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
what 6 structures can a lung tumour locally invade into?
```
recurrent laryngeal nerve
pericardium
oesophagus-causes dysphagia
brachial plexus
pleural cavity-increases more volume of pleural fluid
superior vena cava
```
291
what is a pancoasts tumour?
a tumour of the lung apex
292
when a tumour has invaded bone (causing bone erosion) when will the patient complain the pain is worse?
pain worse at night
293
where are common sites of metastases from a primary lung cancer?
```
liver
brain-fits and headaches
bone
adrenals
skin
lung
```
294
what hormone does a tumour mimic to cause hypercalcaemia?
parathyroid hormone
295
what hormone does a tumour mimic to cause hyponatraemia (abnormally low Na levels)?
ADH
296
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)
Eaton Lambert syndrome
297
why is there pain and tenderness of the long bones in hypertrophic pulmonary osteoarthropathy?
due to elevation of the periosteum away from the bones surface
298
what is the pathophysiology of squamous carcinoma?
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
What is the pathophysiology of Adenocarcinoma?
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
What is the pathophysiology of large cell carcinoma?
Poorly differentiated
high N:C
treated by surgical excision
301
How do you manage Bronchial carcinomas?
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
What is a malignant mesothelioma?
a tumour of mesothelial cells that usually occurs in the pleura and rarely in peritoneum
303
What are the causes of malignant mesothelioma?
asbestos exposure
304
what are the signs and symptoms of malignant mesothelioma?
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
How do you diagnose malignant mesothelioma?
CXR/CT: Pleural thickening/effusion shows also peritoneal deposits
bloody pleural fluid
thoracoscopy- biopsy
pleural tap
306
How do you manage malignant mesothelioma?
Pemetrexed + cisplatin can improve survival
pleurodesis and indwelling intra-pleural drain may help
surgery +/- chemo +/- radiotherapy
307
What causes TB?
mycobacterium tuberculosis complex (MTb)
1. mycobacterium tuberculosis
2. mycobacterium bovis
3. mycobacterium africanum
4. mycobacterium mircroti
they are obligate aerobes
308
What is the pathophysiology of TB?
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
What are the tissue changes in TB?
primary:
Ghon focus forms
Large hilar nodes
secondary:
Fibrosing and caviating apical lesion
310
What are the signs and symptoms of TB?
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
What is miliary TB
TB becomes disseminated following passage into blood stream
causes widespread infection of lung
312
What is the epidemiology of TB?
Majority of cases seen in Africa and Asia (china and India)
co infection of HIV in 12% of cases
313
How do you diagnose TB?
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
How do you manage TB?
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
What are the two main subtypes of influenza
influenza A
influenza B
316
what is haemophilius influenzae?
a Gram-negative, aerobic, small bacilli
mainly a secondary invader
317
What is the transmission of Influenza?
Rapid person to person spread by aerosolised droplets and contact
incubation- 1-4 days
318
What are signs and symptoms of influenza?
```
acute onset Fever, dry cough
sore throat
headache
malaise
eye pain+/- photophobia
conjunctivitis
```
319
what are the complications of influenza?
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
what is influenza in pregnancy associated with?
perinatal mortality
prematurity
smaller neonatal size
lower birth weight
321
How do you diagnose influenza?
mainly clinical acute onset ,cough and fever major sign
Viral PCR
rapid antigen testing
clinical samples (throat swab, nasal swab, sputum)
322
How do you manage influenza?
1. uncomplicated influenza:
Symptomatic therapy- bed rest and paracetamol
2. complicated influenza: risk of complications
antivirals (e.g. oseltamivir and zanamivir)
oseltamivir- PO or NG
zanamivir- inhaled
3. prevention:
post -exposure prophylaxis
annual vaccination
323
what is antigenic drift?
what do they cause?
antigenic drift: small genetic changes during replication which can be accounted for in the annual vaccine
winter epidemics
324
what is antigenic shift?
what do they cause?
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
which subtype is effected by antigenic shift?
influenza A
326
what can also cause influenza pandemics?
non human influenza viruses which transfer to humans are novel
327
what is the name of the H1N1 sub type of influenzae A?
swine flu
328
who is the killed influenza vaccine given to?
adult patients at risks of complications
health care workers
children 6 months - 2 years at risk of complications
(annually)
329
who is the live attenuated vaccine given to?
offered to
all children 2-5
all primary school children
(because live attenuated vaccine more effective in children 2-17 than killed vaccine)
330
what is bronchiolitis?
inflammation of the small airways in the lungs due to viral infection
331
what are the clinical presentations of bronchiolitis?
mainly in children (1-2 years old)
fever
coryza
cough
wheeze
severe cases:
grunting
hypoxia
intercostal in drawing
332
what are the complications of bronchiolitis?
respiratory and cardiac failure
prematuririty
333
what is the aetiology of bronchiolitis?
main cause is respiratory syncytial virus
also caused by metapneumovirus (discovered in 2001)
334
how do you diagnose bronchiolitis?
PCR on throat or pernasal swabs
335
how do you manage bronchioloitis?
supportive therapy
336
What is acute bronchitis?
inflammation of bronchi caused by virus or bacteria infection
337
what are the causes of acute bronchitus?
Mainly viral however secondary bacterial infection from strep pneumoniae or H influenzae is common
338
what are the signs and symptoms of acute bronchitis?
previous URTI
productive cough
tight chestness
wheezing
SOB
339
how do you manage acute bronchitis?
usually supportive
antibiotics if >65 and have COPD
amoxicilin and doxycycline
340
What causes whooping cough (pertussis)?
bordatella perussis
341
what are the signs and symptoms of whooping cough?
flu like symptoms
paroxysmal cough with inspiratory whoop
342
how do you manage whooping cough
high contagious
antibiotics: erythromycin
343
what causes acute epiglottitis?
haemophilius influenzae type B (Hib)
344
what is the main age group affected by acute epiglottitis?
children (2-7)
345
what are the signs and symptoms of acute epiglottis?
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
how do you diagnose acute epiglottis?
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
how do you manage acute epiglottitis?
Phone and call anaesthetist!
ITU and ceftriaxone (a 3rd generation cephlasporin)
prevention: Hib vaccination
348
what are the common signs and symptoms of URTI?
cold: runny nose, nasal congestion
pharyngitis: dry/painful throat
sinusitis: nasal congestion, post nasal drip
clear chest!
349
what are the signs and symptoms of acute laryngotracheobronchitis (croup)?
barking cough
stridor
hoarseness
very severe for children
350
how do you manage acute laryngotracheobronchitits?
nebulised adrenaline- short term only used in emergencies
oral cortiocosteroids (dexamethasone)
oxygen and adequate fluids
351
what is the final stage in tumour development before becoming malignant?
TIS- carcinoma in situ
352
what is The initial stage in tumour development where cells gross appearance and histological findings are altered but there is no malignancy?
Squamous metaplasia
353
what are the clinical features of lingular pneumonia?
pyrexia, dyspnoea and a productive cough.
On chest X-ray, the left heart border is obscured.
354
Describe a granuloma.
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
what is the alveolar macrophage also known as?
dust cell
356
what is the role of CD4 + T cell?
Respond to pathogen peptides bound to HLA class II molecules. Activate other lymphocytes. Produce cytokines and influence phagocyte function. Immunoregulatory cells.
357
what does Coxiella burnetti cause?
ii. what type of infection is it?
pneumonia, or a pyrexia of unknown origin (Q fever)
ii. zoonosis
358
what are the characteristics of DI george syndrome?
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
what causes flu like symptoms in children, secondary to another infection and peaks in incidence in winter epidemics?
metapneumovirus
360
what is Chlamydia trachomatis
ii. how does it transmit?
sexually-transmitted infection that can cause infantile pneumonia
ii.by vertical transmission.
361
what is serum tryptase?
mast cell degradation product that can be measured during an acute episode of anaphylaxis.
362
what might lymphadenopathy look like?
enlarged lymph nodes- can be seen to affect the neck
hilar lymphadenopathy- enlargement of pulmonary lymph nodes
363
What are the causes of pulmonary oedema?
cardiovascular - LVF
ARDS- any cause
fluid overload
neurogenic (head injury)
364
What are the signs and symptoms of pulmonary oedema?
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
How do you diagnose pulmonary oedema?
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
How do you manage pulmonary oedema?
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
5. oral furosemide or bumetanide
6. If large dose of loop diuretic consider adding thiazide
7. 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
what is churg-strauss syndrome?
Eosinophilic granulomatosis with polyangiitis- causes inflammation of blood vessels
368
what are the signs and symptoms of churg-strauss?
triad:
1. adult onset asthma
2. eoinophilia
3. vasculitis
369
How do you diagnose Churg strauss syndrome?
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
How do you manage churg strauss syndromes?
steroids
371
What are the signs and symptoms of Lupus (SLE)
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
How do you diagnose Lupus?
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
A newborn has a diaphragmatic hernia and associated dextrocardia. His repair goes well, but his pulmonary abnormality is persisting what does this suggest?
pulmonary hypoplasia
374
which babies are most likely to suffer from newborn respiratory distress syndrome?
premature babies
375
what does An autoantibody screen reveals anti-CCP antibodies at 1:640 and a raised ESR and CRP suggest?
rheumatoid arthritis
376
what are the causes of pleurisy/pleuritis?
1. pneumonia
2. pulmonary infarct
3. carcinoma
rarer causes
4. lupus
5. rheumatoid arthritis
377
what are the signs and symptoms of pleurisy?
localised sharp pleuritic pain-
worse on:
1. deep inspiration
2. coughing
3. twisting or bending movements
378
what is good pastures syndrome?
rare autoimmune illness with production against the glomerular basement membrane
379
what are the signs and symptoms of good pastures' disease?
pulmonary haemorrhage
glomerulonephritis
haemoptysis
SOB
380
How do you diagnose Good pasture's disease?
CXR: shows pulmonary infiltrates
renal biopsy- crescentic glomerulonephrititis
blood: anti-GBM antibodies
381
what can lisinopril cause?
dry cough - incredibly irritating
drug used for hypertension
382
What is chemical pneumonitis?
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
The visceral pleura should be penetrated during chest drain insertion true or false?
false
384
What is the most common cause of exudative ascites?
Malignancy
Infection
385
What factors are associated with pneumocystisis?
IVDU
progressive Dysopnea
tachyopnea
Batwing cxr
386
What are the causes of pulmonary fibrosis?
Drugs: Bleomycin, azathioprine
pneumoconiosis
occupational lung disease
387
Which type of bronchial carcinoma can Syndrome of inappropriate antidiuretic secretion (SIADH)
small cell
SIADH - retains more water retention but absorbs less sodium
388
How do you diagnose granulomatosis with polyangitis? (GPA)
positive ANCA antibodies
389
How does hypoxia cause RV hypertrophy?
Causes smooth muscle constriction.
this increases pulmonary vascular resistance and hypertension
this increases RV afterload leading to hypertrophy
390
what is usually obscured in left upper lobe pneumonia?
Left heart border
391
what characteristics does Diphtheria have?
```
pseudomembrane affected (swollen throat)
Been to tropics
```
