Clinical Respiratory medicine Flashcards
COPD
Chronic bronchitis and emphysema
Alpha-1-antiprotease deficiency
Inherited enzyme deficiency of alpha-1-antiprotease resulting in emphysema
Chronic bronchitis
Inflamed bronchial tube leading to cough production of sputum most day in at least 3 consecutive months for 2 or more years.
Complicated chronic bronchitis
Acute infective exacerbation of chronic bronchitis - sputum green/yellow
Emphysema
Increased size of airwaves distal to the terminal bronchioles arising from dilation or destructive of alveolar walls and without obvious fibrosis.
Centracinar emphysema
Lossof alveolar walls in upper half of acinar
Panacinar
Massive destruction of acinar, almost all alveolar tissue destroyed
Bullous emphysema
Emphysematous space >1cm, can burst and lead to spontaneous pneumothorax
Peak expiratory flow rate
Simple test that measures peak rate of flow during expiration
Type I respiratory failure
PaO2 <8kPa (CO2 normal or low)
Type II respiratory failure
PaCO2 >6.5kPa (O2 usually low)
Pulmonary hypertension
Increased blood pressure in pulmonary circulation due to vasoconstriction as a result of hypoxic condition
Cor Pulmonale
hypertrophy of the right ventricle of the heart caused by a primary disorder of the respiratory system.
Short acting bronchodilators
SABA (salbutamol and SAMA (ipratropium)
Long acting bronchodilators
LAMA - for COPD (umeclidinium and tioptropium) and LABA (salmeterol)
Asthma
Increased responsiveness of the airways to various stimuli and causes widespread narrowing of airways that changes in severity either spontaneously or as a result of therapy
Atopy
Inherited tendency towards IgE response to allergens
Occupational asthma
Symptoms related to work exposure and no prior history of asthma. Accounts for 10-15% of adult onset asthma, most common in bakers.
Work-excerbated asthma
Asthma symptoms related to work exposure with prior history of asthma.
Pulmonary function test
Lung volume and CO gas transfer tests
Pulsus paradoxus
Change in blood pressure with inspiration/expiration
Leukotriene receptor antagonist
Add on therapy if asthma symptoms not controlled with LABA and ICS alone
Theophylline
Non-Specific phosphodiesterase inhibit and adenosine receptor antagonist. Add on asthma therapy.
‘Wet lung’
Lungs fails to rapidly shift from fluid secreting to fluid absorbing organ at birth
Barker hypothesis
Lung infection shortly after birth restricts total no of alveoli and effects lung function throughout life
Chronic Neonatal Lung Disease
Can develop after RDS and features bronchopulmonary dysplasia. Produces asthma like symptoms and effects lung function later in life.
Respiratory Distress Syndrome
Lack of surfactant production in neonates. Treated with artificial surfactant, oxygen and CPAP.
Primary Microorganisms
Most pathogenic organisms, can infect health and unhealthy people
Facultative Microorganisms
Fairly pathogenic microorganisms - infect people with slightly weakened immune systems
Opportunistic Microorganisms
Only infect people with weakened immune systems
Coryza/Rhinitis
Common cold
Macrophage-mucocillary escalator
Cellular debris and macrophages are moved up out of the respiratory tract by cilia.
Community acquired pneumonia
Pneumonia acquired in primary care
Nosocomial pneumonia
Hospital acquired pneumonia, tends to be more aggressive
Atypical pneumonia
Pneumonia caused by unusual infectious agents
Aspirational pneumonia
Infection by inhalation of gastric contents,
Bronchopneumonia
Diffuse area of infection throughout lung but does not normally affect pleura.
Lobar pneumonia
1 lobe of lung is infected
Hypostatic pneumonia
Collection of fluid in lungs that makes them more susceptible to infection
Obstructive pneumonia
Abscess that obstructs bronchus
Pleurisy
Inflammation of pleura
Empyema
Infection of pleural space
Lung abscess
Collection of pus produced by necrosis of tissue
Pyaemia
Pus forming bacteria in blood
Bronchiectasis
Pathological dilation of bronchi and build up of mucous, most commonly idiopathic
Causes of recurrent lung infection
Local bronchial obstruction, local pulmonary damage (bronchiectasis), generalised lung damage (CF, COPD), non-respiratory disease (HIV, aspiration)
Viral respiratory infectious agents
Adenovirus, influenze A and B, Parainfluenzae I and III, RSV, rhinovirus
Bacterial respiratory agents
Haemophillus influenzae, M catarrhalis, mycoplasma, staph aureus, streptococci
Otitis Media
Infection of ear drum by primary viral infection and then secondary infection with pneumococcus/H. influenzae
Tonsilitis/pharyngitis
Inflammation of tonsils/ back of throat
Stridor
a harsh vibrating noise when breathing, caused by obstruction of the trachea or larynx
Croup
Whooping cough, infection by parainfluenza virus
Pneumonia
Infection of lung tissue (alveoli), most commonly by streptococcus pneumoniae
Purulent sputum
Green/yellow sputum
Pleuritic Chest pain
Sharp pain when breathing in
CURB 65
Severity scoring of pneumonia
Confusion, blood urea >7, respiratory rate >30, diastolic blood pressure <60 and age >65 (1-2 requires hospital, 3-5 requires ITU)
Septicaemia
Infection of blood
Immotile cilia syndrome
Genetic condition causing lack of motile cilia which are unable to clear out mucous. Causes of bronchiectasis
Tracheitis
Infection of trachea causing swelling and constriction , presents similar to croup but with persistent fever and malaise.
Bronchitis
Infection of the bronchi by viral infection and then secondary infection by bacteria due to disrupted mucociliary clearance. Presents with loose rattly cough, self limiting and does not require treatment.
Bronchiolitis
Infection of the bronchioles usually by RSV usually in young children, often confused with asthma. Maximal observation and minimum intervention.
Detection methods of infective organisms
Microscopy and culture of sputum/blood, antigen detection, PCR, serology
Microbiological test for TB
ZN stain, extended culture
Antigen detection methods
Agglutination, ELISA, immuno-fluroescence
Legionella pneumophila
Detection by urinary antigen and sputum culture
Multi-hit theory of carcinogenesis
Between 3-12 genomic changes required to produce invasive phenotype
Main pathways of carcinogenesis in lungs
Lung periphery - adenocarcinoma
Central airways - squamous cell carcinoma
KRAS gene
Common gene associated with adenocarcinoma and induced by smoking
Non-smoking related lung cancer genes
EGFR, BRAF, HER2, ALK rearrangements
Types of carcinoid tumour
Squamous cell, adenocarcinoma, small cell carcinoma, large cell carcinoma
Tumours of bronchial glands
Adenoid cystic carcinoma, mucoepidermoid carcinoma, bengin adenomas
Local effects of lung cancer
Bronchial obstruction, pleura inflammation and invasion, direct invasion of mediastinum and nerves,
Common metastasis sites of lung cancer
Liver, adrenals, bone, brain, skin
Non-metastatic effects
Endocrine effects, hyper-calcemia, inflammatory changes
Prognostic factors of lung cancer
Progression, classification
Performance Status
Scores fitness of patient for treatment from 0-4 (0 being fully active and 4 being bed bound). Stages 0-2 are fit for chemotherapy.
Systematic CXR review
- Name, marker, rotation, penetration
- Lines/metal work
- Heart
- Mediastinum
- Lungs
- Diaphragm
- Soft tissues
- Bones
Pulmonary nodule
An opacity in the lung up to 3cm with no mediastinal adenopathy or atelectasis
Pulmonary mass
An opacity in the lung >3cm with no mediastinal adenopathy or atelectasis
Stage 1 Lung Cancer
Tumour <5cm or involves main bronchus or visceral pleura or associated with atelectasis
Stage 2 Lung Cancer
Tumour <5cm or involves main bronchus or visceral pleura or associated with atelectasis and involves ipsilateral peribronchial, hilar or intrapulmonary lymph nodes.
Or Tumour <7cm, or directly invades chest wall, phrenic nerve or parietal pericardium but no nodal involvement.
Stage 3 Lung Cancer
Tumour <7cm, or directly invades chest wall, phrenic nerve or parietal pericardium and involves lymph nodes.
Or tumour >7cm and invades any major chest structures with or without nodal involvement.
Stage 4 Lung Cancer
Distant metastasis present
Criteria for surgery of lung cancer
No metastasis, and no N2 or N3 nodes involved. Must be fit for surgery - lung function, CVS, psychiatric health
Fatal complications of lung surgery
ARDS, bronchopneumonia, MI, PTE, pneumothorax, intrathoracic bleeding
Non-fatal complications of lung surgery
Empyema, post-thoactomy wound pain, broncho pleural fistula, AF, MI, post-op respiratory insuffiency
Hamartoma
Benign lung tumour, made up of cellular compenents normally found in organ.
Teratoma
Tumour made up of cells not normally found in organ, can be benign or malignant.
Tyrosine kinase inhibitors
Targeted therapy for adenocarcinomas (erlotinib, gefitinib, afatinib)
ZN stain
Used to identify acid and alcohol fast bacilli, namely mycobacterium tuberculosis
Mycobacteria Bovis
Mycobacteria that infects cows and can spread to humans via consumption of milk.
Ghon focus
Calcified nodule caused by macrophages ingesting TB. Mycobacteria proliferate inside macrophage and cause inflammatory response. Tissue necrosis and formation of granuloma with central caseating necrosis follows. Caseating necrosis eventually heals by calcification and creates Ghon focus containing dormant mycobacteria.
Primary complex
Initial lesion and local lymph node involvement in primary TB disease which normally heals and form Ghon focus
Tuberculosis bronchopneumonia
Advanced primary infection in which primary focus cavities and enlarged lymph nodes discharge into bronchus.
Miliary TB
spread of bacilli to multiple sites resulting in systemic upset (respiratory symptoms in majority of cases) . Occurs 6-12 months after infection.
Post-primary TB
Occurs after reactivation of mycobacterium or re-infection from outside source. Can affect any tissue in the body.
Treatment regime of TB
4 months - rifampicin, isoniazid, ethambutol and pyrazinamide
2 months - rifampicin and isoniazid
Side effects of rifampicin
Orange urine and tears, induces liver enzymes (OC ineffective), hepatitis
apnoea
Temporary cessation of breathing for at least 10s
Sleep apnoea
Recurrent episodes of upper airway obstruction leading to apnoea during sleep
Hypopnoeas
Almost complete cessation of breathing
Causes of sleep apnoea
Narrow pharynx, obesity, muscle relaxation
Severity scoring of sleep apnoea
Apnoeas per hr 0-5: normal 5-15: mild 15-30: moderate >30: severe
Narcolepsy
Neurological disorder that causes a person to fall asleep in appropriate times. Features hypnogogic hallucinations, cataplexy and sleep paralysis compared to sleep apnoea which does not.
Causes of chronic ventilatory failure
Airways disease (sleep apnoea, COPD), chest wall abnormalities (kyphoscoliosis), resp muscle weakness (motor neurone, muscle dystrophy), central hypoventilation (obesity hypoventilation syndrome, central hypoventilation syndrome)
Normal sleeping pattern of newborns
16-18hrs sleep, sleep-wakes states alternate in 3-4hr cycles. Periodic breathing is normal.
Polysomnography
gold standard in sleep investigations, not normally required.
Primary snoring
Snoring without apnoea, hypoventilation, hypoxia, hypercarbia or any daytime symptoms.
Pleural effusion
Abnormal collection of fluid in the pleural space
Transudate
Pleural effusion with protein <30g/l
Exudate
Pleural effusion with protein > 30g/l
Common causes of transudates
Left ventricular failure, liver cirrhosis, hypoalbuminaemia, peritoneal dialysis
Common causes of exudates
Malignancy, parapneumonic (lung abscess, pneumonia, bronchiectasis)
Pneumothorax
Breach of the parietal or visceral pleura and entry of air into pleura cavity causing collapse of the lung.
Tension pneumothorax
Break in surface of lung forms 1 way valve that pushes air into pleural space and compresses lung
Primary spontaneous pneumothorax
No clinically apparent disease, due to weight of lung inducing apical blebs that rupture
Secondary spontaneous pneumothorax
Patients has pre-existing lung disease
Traumatic pneumothorax
Due to physical damage of pleura either non-iatrigenic or iatrogenic.
Management of tension pneumothorax
Cannula into 2nd intercostal space, mid-clavicular line then insertion of chest drain
Management of secondary pneumothorax
Chest drain into 4th intercostal space, mid-axillary line if lung does not re-inflate apply suction to drain. (high vol, low pressure) If still no re-inflation then thoracoscopic inspection of pleura and potential pleurodhesis
Pleurodhesis
Attachment of lungs to pleura
Effect of Asbestos
Pleural or peritoneal malignancy
Presentation of pleural malignancy
Dyspnoea, chest wall pain, pleural thickening. Almost uniform mortality.
Interstitum
Connective tissue space around the airways, vessels and the space between the basement membranes of the alveolar walls
Functional consequences of restrictive lung disease
Reduced lung compliance, reduced gas transfer, ventilation/perfusion imbalance, reduction in total lung volume
Honeycomb lung
injury to interstitial lung tissue causing chronic inflammatory response and general diffuse damage to lungs.
Diffuse Alveolar Damage (ARDS)
Acute alveolar damage associated with severe pathological change and huge damage to alveoli. Lungs become solid mass of fibrous tissue.
Pathological changes in diffuse alveolar damage
Pulmonary oedema, formation of fibrin and hyaline membranes, denuded BM, epithelial and fibroblast proliferation and chronic scarring.
Sarcoidosis
Multi-system granulomatous disorder of unknown aetiology
Differentiation between Sarcoid and TB
TB features caseation and necrosis in granulomas
Hypersensitivity Pneumonitis
Group of diseases caused by inhalations of organic macro-moleculer antigens or microorganisms to which host has become sensitised.
Potential antigens in hypersensitivity Pneumonitis
Thermophilic actinomycetes, bird/animal proteins, fungi, chemicals
Usual Interstitial Pneumonitis
Idiopathic patchy interstitial chronic inflammation, type II pneumocytes hyperplasia and smooth muscle and vascular proliferation
Alveolar Hypoventilation
Lack of air moved in and out of lungs/ poor breathing. Treated with increase of fraction of inspired oxygen in air.
Abnormal states associated with hypoxaemia
Alveolar hypoventilation, shunt, ventilation/perfusion imbalance, diffusion impairment
Fibroblastic foci
Fibrous tissue that develops in alveolar wall
Restrictive spirometry
FVC < 80% of predicted normal. Normal FEV1/FVC ratio
Non interstitial causes of restrictive lung disease
Pleural effusion, pneumothorax, amyotrophic lateral sclerosis, rib fractures, obesity, pregnancy
Embolism
Embolism travelling from 1 part of body to another
Risk factors of pulmonary embolism
Major trauma, surgery, pregnancy, cancer, cardiopulmonary disease (MI, COPD), inherited thrombophilia
Symptoms and signs of isolated blood clot in peripheral pulmonary artery
Pleuritic chest pain, cough, haemoptysis, pyrexia, pleural rub and stone dullness at base on percussion
Symptoms and signs of small, bilateral PE
Acute dyspnoea, tachycardia, tachypnoea, hypoxia
Symptoms and signs of large PE
Syncope, cardiac arrest, tachycardia, hypotension, tachypnoea, hypoxia, shock
Pulmonary hypotension
Elevated blood pressure in the pulmonary arterial tree (>25mmHg)
Causes of secondary pulmonary hypotension
Chronic respiratory disease (causing hypoxia and arterial constriction), left heart disease, chronic thromboembolisms
Surgical treatment for lung abscess
Chest drain
Surgical treatment for empyema
Chest drain, pleurectomy and decortication
Open pneumothorax
Major traumatic injury, hole in chest wall is greater in diameter than trachea. Treated with a wet swab creating airtight seal.
Surgical treatment of spontaneous pneumothorax
Pleurodhesis or pleurectomy
Diseases that can lead to need for lung transplantations
CF (double), pulmonary fibrosis, emphysema
Criteria for lung transplantation
<65, not overweight or diabetic, no renal failure or mental illness and good social support network
Commonest mutation in CF
phe508del
Channel involved in CF
Cystic Fibrosis Transmembrane Conductance Regulator - Cl active transport channel and regulates liquid volume of epithelial surface
Pathological changes in CF
Increased absorption of Na, decreased excretion of Cl. Leads to less excretion of water, increasing viscosity of secretions. This leads to cilia collapse and inflammation.
Guthrie Test
Screening test for CF. Tests for immuno-reactive trypsinogen
Treatment of pancreatic insufficiency in CF
Enteric coated enzyme pellets, high energy, low far diet, fat soluble vitamin and mineral supplements and H2 antagonist or proton pump inhibitors
Effects of recurrent bronchopulmonary infection in CF
Scarring (decline lung function) and abscesses
Cardinal features of CF
Pancreatic insufficiency and recurrent bronchopulmonary infection
Non-respiratory manifestations of CF
Crohn’s, coeliac, hepatopathy, diabetes, bilateral abscess of vas deferens, heat exhaustion
Respiratory complications of CF
Bronchiectasis, recurrent LRTI, airflow obstruction, V/Q mismatch, respiratory failure, chronic lung sepsis, pneumothorax
Common infectious agents in CF
Pseudomonas Aerugonosa, Burkholderia cepacia, Strenotrophomonas maltophilia, Mycobacterium abscessus
Cepacia syndrome
Infection of CF patients with Burkholderia cepacia - over activation of immune system and associated with rapid detonation and high mortality rates
Treatment of psudeomonas aeruginosa in CF patients
Oral ciprofloxacin and nebuliser colomycin
Indications for lung transplant in CF patients
Rapidly deteriorating lung function, FEV1 <30% predicated, hypoxia at rest, life-threatening exacerbations
Multi-discplinary CF team
CF nurses, consultants, dieticians, physiotherapists, psychologist, pharmacist, microbiologist, genetics staff, GP
Contra-inidcations for lung transplant in CF
Other organ failure, malignancy within 5 yrs, peripheral vascular disease, drug, nicotine or alcohol dependency, active systemic infection (or infection with Mycobacterium abscessus)
