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4TH YEAR > CSIM lungs > Flashcards

CSIM lungs Flashcards

1
Q

three reasons you see a diffusely abnormal CXR?

A
  1. impaired gas transfer
  2. reduced lung volume
  3. restrictive ventilatory function (stiffened or shrunken lungs)
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2
Q

ratio of FEV1 : FVC in an obstructive picture?

A

FEV1 < FVC

< 70% is diagnostic

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3
Q

in obstructive disease why is there gas trapping and what symptom does this cause?

A

bronchiole collapse on expiration

difficult to exhale completely

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4
Q

when is bronchiolitis seen in adults?

A

transplants
rheumatoid disease
idiopathic
chemical exposure

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5
Q

Lung biopsy - focal bronchiolar fibrosis and fibroblast proliferation
most likely diagnosis?

A

bronchiolitis

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6
Q

define bronchioles

A

branches of a bronchus that are smaller than 2mm and have NO cartilage

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7
Q

what is hypersensitivity pneumonitis?

A

AKA extrinsic allergic alveolitis - inflammation of the alveolar due to inhaled dust particles

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8
Q

define pneumoconiosis and give examples

A

lung disease from mineral dust
it can be fibrogenic or non-fibrogenic

silicosis
coal works pneumoconiosis
asbestosis

those are all FIBROGENIC

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9
Q

who is at risk of silicosis

A

working with:
concrete
sand blasting
artificial stone

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10
Q

why is sand not dangerous?

A

silica only dangerous when an unnatural force is applied to it to make it smaller

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11
Q

characteristic finding on biopsy in silicosis?

A

dense fibrosis with bi-refringent particles

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12
Q

characteristic finding on biopsy in coal miners pneumoconiosis

A

Dust accumulation around terminal bronchioles with fibrosis

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13
Q

light exposure to asbestos is associated with what?

A

pleural disease (mesothelioma, pleural plaques /fibrosis )

need heavy exposure to affect lungs

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14
Q

what is the radiological marker of asbestos exposure?

A

pleural plaques - these will be asymptomatic

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15
Q

whos at risk of siderosis and what is it?

A

welders - this is a non-fibrogenic pneumoconiosis

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16
Q

what do pleural plaques look like on CXR?

A

holly leaves (they dont really)

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17
Q

most common complication of pleural plaques?

A

benign diffuse pleural thickening -> fluid accumulation -> breathlessness

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18
Q

two things that can help differentiate ILD from asbestosis?

A

IDL :
dont get plaques
can get clubbing ( never clubbing in asbestosis)

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19
Q

when does malignant mesothelioma present?

A

~30 yrs post exposure

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20
Q

why is there a reduced lung volume in malignant mesothelioma ?

A

diffuse pleural thickening

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21
Q

what are TLCO and KCO?

A

they are both measurements of the transfer factor of CO
they are used to assess the integrity of the gas–exchanging part of the lung

TLCO = transfer factor for the lung for carbon monoxide i.e. Total diffusing capacity for the lung
KCO = transfer coefficent i.e. Diffusing capacity of the lung per unit volume, standardised for alveolar volume (VA)
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22
Q

what systemic symptom is there in extrinsic allergic alveolitis?

A

shivers after exposure due to immunological response

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23
Q

4 causes of L tracheal deviation?

A
  1. right tension PT
  2. L lobar collapse
  3. goitre
  4. right pleural effusion
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24
Q

5 causes of unilaeral pleural effusion

A 
lung cancer
mesothelioma
TB
pneumonia
asbestosis
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25
Q

how does asbestosis cause pleural effusion?

A

diffuse pleural irritation causes the blood vessels to be leaking

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26
Q

how is a pleural tap made safer?

A

US guidence

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27
Q

what tests are done on pleural fluid?

A

bio chem: protein, glucose, pH, LDH (lactate dehydrogenase)

culture and sensitivity

TB test

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28
Q

sensitivity and specificity in cytological exam of pleural fluid?

A

looking for cancer cells:
if present then definitely cancer
not always present in cancer
i.e. specific not sensitive

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29
Q

differences on CT between benign and malignant pleural disease

A

malignant mesothelioma: lumpy and affects the whole way round the lung including mediastinum

benign: just thicker but still smooth

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30
Q

what screening would you do for mesothelioma in people who are a high risk?

A

none because there is no treatment :(

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31
Q

commonest cause of new onset breathlessness before 32?

A

asthma

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32
Q

some occupations that increase risk of astma

A

farming
painting
plastics
cleaning

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33
Q

what type of allergen react with specific IgE antibodies?

A

high molecular weight allergens e.g. flour

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34
Q

when does occupational asthma occur?

A

normally within a year of new work after a latent interval of symptomatic exposure

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35
Q

when in the day is occupational asthma worst?

A

at work and evening / nighttime

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36
Q

how much asthma is occupational

A

1/6 cases

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37
Q

on going exposure to occupational allergens can lead to what?

A

progressive and permanent asthma

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38
Q

what immunological investigations can be done to help diagnose asthma?

A

RAST: specific IgE

skin prick test

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39
Q

what is the airway responsiveness test and when is it used?

A 
inhale bronchoconstrictor (histamine) and see how much the airway narrows
asthmatics narrow more
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40
Q

4 types of investigation in diagnosing occupational asthma

A

immunological
serial PEF
serial airway responsiveness test
inhalation challenge (inhale allergen)

diagnosis on Hx alone is unreliable

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41
Q

who’s duty to report occupational hazards?

A

the employer

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42
Q

what is a RAST test and how is that different to a skin prick test?

A

Radioallergosorbent test - blood test for specific IgE antibodies to determine the substance to which a person is allergic to

skin prick test looks at how the skin reacts to different substances

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43
Q

define chronic bronchitis

A

Chronic or recurrent excessive mucus secretion in the bronchial tree due to irritation

productive cough lasting longer than 3 months on two consecutive years

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44
Q

define emphysema

A

An increase beyond the normal in the size of the air spaces distal to the terminal bronchiole accompanied by destruction of their walls and without obvious fibrosis

basically destruction of the alveolar walls increases the size of the air spaces

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45
Q

which drug given in COPD can be considered a disease modifying drug and why?

A

regular tiotropium leads to reduced hospitalizations due to exacerbations

46
Q

treatment pathway for COPD

A

smoking cessation
flu jab

SABA
LAMA
ICS / LABA

pulmonary rehab

47
Q

how can anxiety in COPD be addressed?

A

CBT

48
Q

define cor pulmonale

A

right side HF caused by lung disease

49
Q

cor pulmonale pathophys. ?

A

in emphysema all parts of the lung are hypoxic so there is vasoconstriction over the whole lung (an attempt to get blood to parts that ARE well ventilated)
this means the heart is effectively pumping against a ‘closed door’

50
Q

how is V/Q matching suppose to work?

A

vasoconstriction in areas of the lung that have poor ventilation means that more blood gets to the better ventilated parts

51
Q

who is LTOT indicated in?

A 
PaO2 < 7.3 when stable
OR
PaO2 <8 AND ONE OF
- secondary polycaethemia
- peripheral oedema
- pulmonary hypertension
- nocturnal hypoxaemia
52
Q

define hypoventilation?

A

abnormal breathing leads to insufficient ventilation causing hypercapnia

53
Q

how does COPD cause hypoventilation?

A

increased dead space in the lungs: breaking down the alveolar walls

reduced perfusion:

  • due to compression (due to overinflated lungs) of capillaries
  • destruction of pulmonary vasculature
54
Q

define type 2 resp failure

A

low O2
high CO2
ACIDOTIC

55
Q

Mx for type 2 resp failure?

A

O2 aiming for 88-92% (chemoreceptor for CO2 does not stimulate patient to breath so keep them a little bit hypoxic)

steroids, NEBs and maybe abx

consider non invasive ventilation (reduced mortality by 50%)

56
Q

what is obstructive sleep apnoea?

A

upper airway narrowing provoked by sleep -> sleep fragmentation -> significant daytime symptoms

57
Q

pathophys of OSA?

A

dilator muscles (mainly pharyngeal dilator) fail to maintain airway patency so repeated arousal is needed to reactivate dilator.
some narrowing is normal, it can be excessive when:
- sedatives e.g. alcohol
- NM disorder effecting the pharyngeal muscle
- mass overloading

58
Q

prevalence of OSA in the UK?

A

0.5 -1 %

59
Q

why is OSA more common in men?

A

fat distribution

60
Q

clinical features of OSA?

A

from most common to least:

snoring with periods of apnoea
excessive sleepiness / poor concentration
loss of libido
nocturia
unrefreshing sleep
nocturnal sweating
61
Q

exam findings in OSA?

A

pink (polycythaemia)
obese
associated with acromegaly
large neck circumference

62
Q

what score can be used to assess tiredness and whats an abnormal score?

A

Epworth

<9 is abnormal

63
Q

how does OSA lead to HF?

A

cor pulmonale due to hypoxia

64
Q

how does cpap work?

A

delivers constant pressure to splint airway open

65
Q

pro and cons of cpap?

A 
highly effective
poorly tolerated (dedicated cpap nurse for education)
66
Q

who must patients inform about OSA?

A

DVLA ( only allowed to drive after 3 months of compliance with treatment)

67
Q

best investigation for assessing OSA?

A

polysomnogram

68
Q

3 investigations in OSA?

A

ABG
pulmonary function test
CXR

also always do a neuro-exam

69
Q

in ILD, what is the interstitium?

A

the cells between the basement membrane of the alveolar and other alveolar and between the alveolar and capillaries

70
Q

if ILD is suspected, what questions do you need to ask yourself before tx?

A

is there an underlying cause?
?sarcoidosis
?acute/ chronic hypersensitivity pneumonitis

71
Q

what are the possible underlying causes of ILD?

A

connective tissue disease
drugs
organic dust
inorganic dust

72
Q

define pneumonia

A

inflammation of the alveolar

73
Q

two most common connective tissue diseases associated with ILD?

A 
RA (low percecntage but high burden due to amount of RA)
systemic sclerosis (high percentage but low burden as it's rare)
74
Q

common drugs that cause ILD?

A 
methotrexate (DMARD for RA)
amiodarone (for arrhythmias)
nitrofurantoin (for UTIs)
bleomycin (for cancer)
radiotherapy
75
Q

inorganic dust that cause ILD?

A

asbestos, coal ( technically organic), silica

76
Q

organic dust that causes ILD?

A

farmer’s lung
pigeon fancier’s lung
mould in the house

77
Q

Raynaud’s phenomenon is typical of what?

A

connective tissue disease

78
Q

what questions to ask to rule out CT disease in ILD?

A

cold/ pale hands
dry eyes / mouth
muscle pain
joint pain

79
Q

reflux is common in what cause of ILD?

A

systemic sclerosis

80
Q

sound of lungs in ILD?

A

velcro crackles at base of lungs

81
Q

what do squeaks on inspiration suggest?

A

hypersensitivity pneumonitis

82
Q

Ix in suspected ILD?

A

CXR

CT

83
Q

appearance of ILD on CXR?

A

shaggy boarders to the lungs where there has been thickening of the interlobular membranes

84
Q

what imaging is best in ILD and why?

A

CT: 1 mm helical scan prone and supine, on insiration and expiration
CXR is very non-specific

85
Q

in ILD how can you tell fluid from interstitial disease on CT?

A

do the scan PRONE and SUPINE, if the suspicious area disappears when the patient is turned over then it’s just fluid

86
Q

why do an expiratory CT scan in ILD?

A

in ILD: on expiration the bronchioles will snap shut too early and this will lead to a mosaic pattern (air trapping)

87
Q

define usual interstitial pneumonia

A

this is the histological hallmark of IPF:
normal healthy alveolar next to destroyed lung

this is also seen on CT

88
Q

what is it that restricts the lung function on ILD?

A

band of fibrosis inhibits elastic quality of lung

89
Q

when is ILD usually diagnosed?

A

72 yrs

90
Q

classical presentation of ILD?

A

progressive breathlessness and dry cough

91
Q

what is the typical prognosis of ILD?

A

poor but very varable

92
Q

blood tests in ILD?

A

Autoantibodies

  • RhF/anti-CCP,
  • extractable nuclear antigens (anti-Ro/La/Jo-1)
  • Anti-dsDNA,
  • ANCA

Angiotensin converting enzyme (ACE)/calcium (sarcoid)

Precipitating antibodies (hypersensitivity pneumonitis)

93
Q

what is sarcoidosis?

A

Chronic, multi-system granulomatous disease

of unknown aetiology

94
Q

diagnosis of sarcoidosis?

A

diagnosed by characteristic features:
- bilateral lymphadenopathy on the neck

rarely biopsied

95
Q

what are the three component to pulmonary function tests?

A

spirometry: FEV1 , FVC
lung volumes: TLC, RV
transfer factor: TLCO, KCO

96
Q

what is the disadvantage of the transfer factor test?

A

have to be able to hold breath for 10s , lots of patients cant do that

97
Q

draw out flow-vol. loops for normal lungs, large airway obstuctioin and small airway obstruction

A

normal - upside down V
large airway disease- looks like a BURGER
small diffuse airway disease - looks like a church and steeple

98
Q

on a flow-vol graph:
what is the point where the line crosses the x axis?
what is the top of the curve?

A

FVC

Peak expiratary flow

99
Q

how can spirometry be normal in asthma patients?

A

asthma is a variable and reversible disease

100
Q

what will TLC and RV look like in an obstructive picture?

A

TLC -raised due to chronic hyper inflation

RV - raised due to gas trapping

101
Q

RV in restrictive picture

A

falls / same

102
Q

what things decrease the TLCO

A

Ventilation Perfusion Mismatch - common in many lung diseases
Reduction in the area of alveolar-capillary membrane - e.g. emphysema
Increased thickness of alveolar-capillary membrane - e.g. pulmonary fibrosis
Pulmonary Blood flow - e.g. pulmonary hypertension
Haemoglobin concentration - e.g. anaemia leads to a decrease in TLCO

103
Q

in a healthy person with one lung what will the KLO and TLCO be?

A

KLO - 100%

TLCO - 50%

104
Q

TCLO and KCO in asthma?

A

both normal

105
Q

TLCO and KCO in COPD?

A

both decreased

106
Q

TLCO and KCO in ILD?

A

both decreased

107
Q

in extra-thoracic restrictive conditions e.g. obesity what will the KCO and TLCO be?

A

TLCO - decreased

KCO - can be increased due to lung working even harder to keep up

108
Q

what imaging is most useful in ILD?

A

high resolution CT - more detail in each picture but less frequently taken (every 10mm ish)

109
Q

what 5 conditions can asbestos cause?

A
  1. pleural plaques - asymptomatic
  2. pleural fibrosis - benign breathlessness
  3. mesothelioma
  4. lung cancer
  5. asbestosis (pulmonary fibrosis caused by asbestos)
110
Q

which conditions require heavy exposure to asbestos?

A

lung cancer and asbestosis

4TH YEAR (12 decks)

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