Lung Pathology Flashcards
1
Q
WHAT ARE THE DIFFERENT MODES FOR OLD TO GET?
A
Vapour.
Gases.
Dusts.
Fume.
2
Q
What is vapour or gases?
A
Liquid or solid substance suspended in air.
Including mists.
3
Q
What is dust?
A
Aerosolised solid particles. Size from 1 to less than 100 nanometers.
4
Q
What is a fume?
A
Normally vapour or gas.
5
Q
When do most occupational lung disorders occur?
A
After a period of latent (asymptomatic) exposure.
6
Q
What improves prognosis in OLDs? What do you need to weigh up though?
A
Earlier recognition
Identify and cease exposure
Health versus income
Loss of employment
Eg allergic OA
7
Q
What is the problem with historical exposure factors for OLD? What effect does this have on prognosis?
A
Recognised years later
Not normally exposed
Supportive measures
Little/no impact on prognosis
Benefits advice
Eg asbestosis
8
Q
What factors do you have to think about when looking at OLDs?
A
Susceptibility
Genetic/individual vs population
Severity
No sx vs disability/death
Reversibility
Reversible vs irreversible
Employment
Working vs employed
9
Q
What are the most common OLDs?
A
Asthma.
Allergic alveoli’s.
Bronchitis/empyhsema.
Non-malignant pleural disease.
Mesothelioma.
10
Q
How can occupational asthma be caused?
A
90% Asthma induced by sensitisation (allergy) to an agent inhaled at work.
10% Asthma induced by massive accidental irritant exposure at work (direct airway injury).
11
Q
How much of adult onset asthma does occupational asthma take up?
A
9-15%.
12
Q
What happens with occupational asthma prolonged exposure?
A
Ongoing exposure worse prognosis
Early identification important
Treat or even cure
13
Q
What would some tests of occupational asthma show?
A
Normal spirometry.
Work-effect confirmed by seal PEF.
Positive IgE to wheat flour.
14
Q
What is an example of allergic sensitisation?
A
Extrinsic allergic alveolitis
Note, Asthma is also one
15
Q
Where was extrinsic allergic alveolitis first recognised?
A
Farmers
16
Q
How can extrinsic allergic alveolitis be caused?
A
Occupational or environmental.
17
Q
What is extrinsic allergic alveolitis?
A
An interstital lung disease
Upper lobe predominant, gas trapping, ground glass, progresses to fibrosis.
18
Q
How is extrinsic allergic alveolitis classed?
A
Duration
Acute (may be self-limiting).
Subacute.
Chronic (scarring).
19
Q
What are the different occupational hazards for extrinsic allergic alveolitis?
A
Microorganisms.
Animals.
Vegetation.
Chemcials.
20
Q
What are the different microorganisms causing for EAA?
A
FARMERS!
wood pulp workers, sewage workers, maple bark strippers, cheese washers, metalworking engineers, mushroom workers, suberosis, bagassosis
21
Q
What animals, vegetation and chemicals can cause EAA?
A
Animals
Birds, wheat weevil, fish meal, rodent handlers
Vegetation
Coffee, wood
Chemicals
Vineyard sprayers, insecticide, isocyanates, anhydrides, plastics
22
Q
What does prognosis of EEA depend on?
A
Early recognition and avoiding exposure.
23
Q
What is an example of Chronic inflammation?
A
COPD.
24
Q
What percentage of COPD happens within occupational exposure?
A
10-15%.
25
What historic VGDF substances cause COPD?
Coal, silica, grain
26
What is an occupational hazard that can cause COPD?
Dust exposure.
27
What deficiency makes a person more likely to develop COPD?
Alpha-1 antitrypsin deficiency.
28
What are some asbestos-related lung diseases?
Pleural plaques
Diffuse pleural thickening.
Asbestosis.
Lung cancer.
Mesothelioma
29
What is asbestos?
Naturally occurring mineral fibre
Used for millenia
Insulating, fire-retardant, tensile strengh
30
What are pleural plaques and why are they important in asbestos-related lung diseases?
Pleural collagen, often calcified.
Marker of exposure.
Not pre-malignant.
Aetiology unclear.
31
What is diffuse pleural thickening and what can it cause in asbestos-related lung disease?
Follows benign effusion
Obliteration of costophrenicangle
**_Can cause_**
Restriction due to thickened pleura
SOB, respiratory failure
32
Is there any treatment for diffuse pleural thickening?
No effective treatment.
May progress slowly (without further treatment).
33
What is asbestosis and what does it show in asbestos-related lung disease?
Pulmonary fibrosis
Subpleural, basal, UIP pattern.
With/without plaques.
History of heavy exposure.
34
Is there any treatment for asbestosis?
No effective treatment.
May progress (without further exposure).
35
What is mesothelioma in asbestos-related lung disease?
Rapidly progressive and usually incurable pleural cancer
Lung encased by tumour
36
How does mesothelioma present in asbestos-related lung disease?
Often presents as an unexplained pleural effusion
Progressive breathlessness, chest pain, weight loss
Average survival 8-14 months.
37
How can you prevent OLDs?
Requirement under COSHH.
Focus on exposure prevention or minimisation.
38
What procedures can you do to help prevent OLDs?
Elimination (eg asbestos)
Substitution (eg latex to nitrile gloves)
Engineering controls (eg exhaust ventilation)
Worker education
RPE (masks and respirators)
39
What can you do if there is an individual risk to a patient?
Yearly questionnaire/spirometry/CXR
Identify ill health early
Prevent further harm by reducing/preventing exposure
Review control measures to protect other workers
40
What are some chronic obstructive diseases?
Chronic bronchitis and/or emphysema
Asthma
Bronchiectasis
41
WHAT IS COPD?
Collection of lung diseases that cause IRREVERSIBLE obstruction to airflow out of the lungs.
42
What are the causes of COPD?
Smoking
A1AT
IV drug use
Industrial exposure to chemicals
43
WHAT IS CHRONIC BRONCHITIS?
https://www.youtube.com/watch?v=Y29bTzKK\_P8
Bronchial tubes inflammation
IRREVERSIBLE
44
What is chronic bronchitis defined as?
Cough, sputum production on most days for 3 months of 2 successive yrs
45
What are the different layers of the airways?
**_Mucosa_**
Epithelial cells
Goblet cells
**_Lamina propria_**
Basement membrane
Loose connective tissue
**_Submucosa_**
Smooth muscle
Connective tissue
Cartilage (bronchi)
46
What does smoking cause?
What does this cause?
In chronic bronchitis
Hypertrophy and hyperplasia of the mucinus glands (bornchi)
Hypertrophy and hyperplasia of goblet cells (bronchioles)
Increase in mucus
Cilia also become short and less motile
Harder to move mucus
Air trapping
47
How can pulmonary hypertension happen in chronic bronchitis?
Decreased gas exchange causign vasocontriction
Large proportion
Increases pulminary vascular resistance
Develops pulmonary hypertension
Right side of heart enlarges
Cor pulmonale
48
How can a person become cyanosed in chronic bronchitis?
CO2 trapped in alveoli takes up more space
O2 unable to fill alveoli
Less goes into the blood
More CO2 in alveoli means less CO2 can come out the blood
More CO2 in blood less O2
49
What is the reid index?
Size of the mucinus glands relative to the rest of the layers
50
Who does chronic bronchitis affect?
Affects middle aged heavy smokers
Some following pollution chronically
Recurrent low grade bronchial infections
51
What are the symptoms of chronic bronchitis?
Wheeze
Crackles
Cough
Production of mucus (sputum)
52
What are the signs of chronic bronchitis?
Hypoxemia
Hypercapnia
These cause **_cyanosis_**
Pulmonary hypertension
Result of low O2
Causing **_cor pulmonale_**
Tachypnoea
Use of accessory muscles
Hyperinflation
53
What are the differential diagnosis for chonic bronchitis?
Alpha1-Antitrypsin Deficiency
Asthma
Bronchiectasis
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Sinusitis
Gastroesophageal Reflux Disease
Influenza
54
What are the investigations for chronic bronchitis?
**_Chest X-ray_**
Rule out other lung conditions, such as pneumonia.
**_ECG_**
Right venticle and atria enlargment (cor pulmonale)
**_Sputum_** (bacteria).
**_A pulmonary function test_**
**_CT scan_**
**_ABG: PaO2 decrease ± hypercapnia_**
55
What are the management options for chronic bronchitis?
Reduce risk factors.
**_Medications_**
A bronchodilator.
**_Theophylline_** is an oral medication that relaxes the muscles in your airways.
**_General_**
Short-acting antimuscarinic (ipratropium) or salbutamol
**_Mild/Moderate_**
Long-acting antimuscarinic (tiotropium) or salmeterol
**_Corticosteroids if severe plus long acting_**
Beclamethosone
**_Antibiotics_**
Pulmonary rehabilitation. It often consists of exercise, nutritional counseling, and breathing strategies.
56
WHAT IS EMPHYSEMA?
What are the different types?
https://www.youtube.com/watch?v=TEuSV\_7gWA8
Enlargement of alveolar airspaces with destruction of elastin in walls.
**_Centri-acinar_**
(proximal part of acinus due to smoking)
(top of lungs)
**_Pan-acinar_**
(All acinar affected)
(Genetic condition alpha1-antitrypsin)
(Bottom of lungs)
**_Paraseptal acinar_**
(Distal acinus)
(Periphery of lungs)
(Pneuthorax)
57
What are the causes of emphysema?
Cigarette smoking. (MAINLY)
Alpha-1-antitrypsin deficiency
Coal dust exposure
Cadmium toxicity
58
What happens when the alveoli becomes irritated by smoke?
What does this do?
What happens when exhaling?
Triggers an inflammatory response, immune cells come in
Releasing inflammatory mediators
(Proteases, Collangenases)
Breaks down the collagen and elastin in the alveoli wall
**_Bernoulli principle_**
Exhalation of air has a lower pressure and pulls the airway inwards, ormal airways can withstand this
Emphysema airways have less elastin and collagen therefore collapse
**_Leads to air trapping_**
59
What happens when air comes into emphysema lungs?
Lungs are more compliant
Lungs overinflate
60
What happens in alpha-1 antitrypsin deficiency?
Macrophages produce proteases
Helps clear debris
Can damage tissue
Alpha-1 antitrypsin is a protease inhibitor
Protects against damage
Deficiency means proteases can damage lungs
61
What are the oxygen and carbon dioxide levels in emphysema?
‘pure’ emphysema appears with reduced PaCO2 and normal PaO2 at rest due to overventillation (‘pink puffers’)
62
What are the symptoms of emphysema?
Dyspnea - shortness of breath
Exhaling through pursed lips to keep lungs inflated
Cough - sputum
Weight loss due to metabolic demands
1/3 of lung capacity is destroyed before symptoms
63
What are the signs of emphysema?
Barrel chest - overinflated chest on x-ray
Flattened diaphragm
Pulmonary hypertension
Right heart failure
64
What are the differential diagnosis of emphysema?
Bronchiectasis
Bronchitis
Lymphangioleiomyomatosis
65
What are the investigations for emphysema?
**_Blood tests_**
Hb level increase secondary polycythaemia.
**_Chest x-ray_**
This helps to show hyperexpansion of the lungs.
**_ECG or Echocardiogram_**
Right heart failure (a complication of emphysema and COPD).
**_Pulmonary/Lung Function tests_**
Spirometry is the best test to detect airflow limitation and obstruction.
**_Blood gases_**
Normal, later stages of disease, low oxygen and high carbon dioxide levels.
**_High resolution CT_**
Best test for detecting emphysema and bullae (big dilated air spaces).
66
What is the treatment for emphysema?
Stop smoking
**_General_**
Idotropium or salbutamol
**_Mild/intermediate_**
Tiotropium (antimuscarinic)) and salmeterol
**_Severe_**
corticosteroids (beclemethosone)
67
What are the complications of COPD?
Pneumothorax
Cor pulmoale
Acute exaccerbations
Infection
68
WHAT IS BRONCHIECTASIS?
https://www.youtube.com/watch?v=rTcVPHszU5E
Irreversible dilation of the bronchioles
69
What are the causes of bronchiectasis?
```
**_Congenital_**
Cystic fibrosis (CF);
```
**_Post-infection_**
TB
HIV
```
**_Other_**
Bronchial obstruction (tumour, foreign body)
```
70
What is the pathology of bronchiectasis?
Infection and imparied drainage
Activates neutrophilic proteases and cytokines causing inflammation
Increaed mucus and increased stagnent bacteria
Cycle starts again
71
What are the signs and symptoms of bronchiectasis?
Chronic cough - foul smelling sputum
Flecked with blood sometimes.
Finger clubbing
Coarse inspiratory crepitations.
Wheeze
72
What are the differential diagnosis for bronchectasis?
Alpha1-Antitrypsin Deficiency
Aspiration Pneumonitis and Pneumonia
Asthma
Bronchitis
Chronic Obstructive Pulmonary Disease (COPD)
Cystic Fibrosis
Emphysema
Gastroesophageal Reflux Disease
73
What are the tests for bronchiectasis?
**_Sputum culture_**
**_HRCT chest_**
To assess extent and distribution of disease.
**_Spirometry_**
Obstructive.
**_Chest X-Ray_**
Cystic shadows, thickened bronchial walls
74
What is the management for bronchiectasis?
Stop smoking
Airway clearance exercises
Bronchodilators
Corticosteroids
Antibiotics
75
What are the complications with bronchiectasis?
Pneumonia
Emphysema
Septicaemia
Amyloid formation.
76
WHAT IS ALPHA-1 ANTITRYPSIN DEFICIENCY?
A deficiency in alpha-1 antitrypsin
77
What does alpha-1 antitryspin do?
What is the gene that codes for it?
What chromosome is it on?
Inactivates elastase (a protease)
SERPINA1
Long arm of chromosome 14
78
What happens when there is infection or inflammation in the lungs?
What does A1AT do?
What happens if there is no A1AT?
Neutrophils
Neutrophils make neutrophil elastase
Break down bacteria but also elastin in the walls
Liver makes alpha-1 antitrypsin which travels to lungs and inhibits this
Neutrophil elastase breaks down alveoli wall
Alveoli lose elasticity and structural intengrity
79
When would you favour alpha 1-antitryspin deficiency as a dignosis?
Never smoked
Young
80
What are the symptoms of alpha-1 antitrypsin deficiency?
Shortness of breath
Wheezing
Mucus production
Chronic cough
**_Cirrhosis_**
Inability to make coagulation factors
Build up of toxins
81
What investigations are done for alpha-1 antitrypsin deficiency?
**_Bloods_**
A1AT low
**_Biopsy_**
Liver - Periodic-acid shiff stain
82
What is the treatment of alpha-1 antitrypsin deficiency?
**_Augmentation therapy_**
IV infusion of normal protein
Slow of halts progression
Inhlaers
Oxygen
Liver transplant
83
WHAT ARE INTERSTITIAL LUNG DISEASES?
Disease of the alveoli primarily
Scarring
Fibrosis
84
What are the symptoms of interstitial lung diseases?
Dry cough
Digital clubing
Diffuse inspiratory crackles
Dysponea
85
What can acute interstitial lung diseases cause?
Acute respiratory distress syndrome
86
What are the causes of acute respiratory distress syndrome?
Shock
Trauma
Infections
Gas inhalation
Narcotic abuse
87
What are the symptoms of acute respiratory distress syndrome?
Tachypnoea
Dyspnoea
Pulmonary oedema
88
What are some Chronic interstitial diseases? (Differential diagnosis of eachother)
Idiopathic
Pneumoconiosis
Extrinsic Allergic Alveolitis/ Hypersensitivity pneumonitis
Sarcoidosis, connective tissue disease etc.
89
What is pneumoconiosis?
Lung disease caused by inhaled dust Organic or inorganic dust (mineral)
90
What happens in coal workers' pneumoconiosis?
Coal is ingested by alveolar macrophages (dust cells)
They aggregate around bronchioles
The consequences vary from trivial to lethal.
91
What is Caplan's syndrome?
The association between rheumatoid arthritis, pneumoconiosis, and pulmonary rheumatoid nodules.
92
How do you treat pneumoconiosis?
Avoid exposure to coal dust
Treat co-existing chronic bronchitis
93
What happens in silicosis?
Inorganic minerals abundant in stone and sand
Toxic to macrophages, leading to their death with release of proteolytic enzymes.
Tissue destruction and fibrosis
Nodules are formed after many years of exposure.
94
How do you treat silicosis?
Avoid exposure and claim compensation.
95
What is asbestosis caused by?
Inhaltion of asbestos.
96
What are the features of asbestosis?
Similar to other fibrotic lung diseases with progressive dyspnoea, clubbing, and fine end-inspiratory crackles.
Also causes pleural plaques, increased risk of bronchial adenocarcinoma and mesothelioma.
97
What is the management of asbestosis?
Symptomatic.
Patients are often eligible for compensation through the UK Industrial Injuries Act.
98
WHAT IS EXTRINSIC ALLERGIC ALVEOLITIS?
https://www.youtube.com/watch?v=PIuj6XiMlps
Inflammation of the alveoli due to an extrinsic allergen of known type
99
What are two types of extrinsic allergic alveolitis?
**_Bird fancier’s lung_**
Avian proteins in droppings
Antigens
**_Farmer’s lung_**
Caused by fungus (poorly stored / mouldy hay)
100
What is the pathology of EAA?
What type of sensitivity is it?
Allergens comes in
Irritates alveoli and activates neutrophils
Releases inflammatory cytokines
Cascade leads to B cell antibody prodction
Complexes form
TYPE 3
101
What are the two types of EEA?
Acute (few hours after only inflammation)
Chronic (fibrosis)
102
What is seen in chronic that is not seen in acute EAA?
Granulomas
Non-caseating
Macrophages fuse with eachother making granulomas
103
What are the symptoms of extrinsic allergic alveolitis?
**_Acute_**
Fever
Rigors
Myalgia
Dyspnoea
Crackles (no wheeze).
**_Chronic_**
Increasing dyspnoea
Weight decrease
Exertional dyspnoea
Type I respiratory failure
Cor pulmonale.
104
What are the tests for extrinsic allergic alveolitis?
**_CXR_**
Upper-zone mottling/consolidation
Honeycombing sometimes
**_Blood_**
FBC (neutrophilia); ESR increase; ABGS; positive serum precipitins (indicate exposure only).
**_Lung function tests_**
Restrictive defect; reduced gas transfer during acute attacks.
105
What are the management options for extrinsic alergic alveolitis?
Remove allergen
O2
Oral prednisolone
106
What is the difference between asthma and EAA?
**_Asthma_**
Obstructive
Larger airways
Type 1 allergic
**_EAA_**
Restrictive
Smaller airways
Type 3 and 4 allergic
107
WHAT IS SARCOIDOSIS?
https://www.youtube.com/watch?v=D-ahTqbqnqE
Granulomatous disease affecting mainly the lungs, but also lymph nodes in a greater frequency.
108
What type of granuloma is sarcoidosis?
Non-ceasiating granulomatous disease
109
What is the epidemology of sarcoidosis?
African-americans
Women more than men
Under 40 years of age
Non smokers
110
What is the cause of sarcoidsis?
What cells are disregulated?
Unknown
Disregulation of CD4 cells
111
What happens when an uknown antigen comes into the body in sarcoidosis?
Unknown cell comes in
Picked up by macrophages
Takes to lymph node
CD4 cell gets antigen preseted
Proliferation of CD4 cells occur
Macrophages get activated and clump together
112
What are the pulmonary symptoms of sarcoidosis?
4 D's!
113
What are the non-pulmonary symptoms of sarcoidosis?
Skin – erythema nodosum
Arthritis - esp. of feet, hands
Respiratory - pulmonary infiltrates
Cardiac– heart block, VT, heart failure
Ocular– anterior uveitis, can lead to blindness
Intracranial (brain) – chronic meningitis, seizures, neuropathy
Derangement of liver and renal function – hepatic granuloma (70% patients), hypercalcaemia(
114
What are the tests for sarcoidosis?
**_Tissue biopsy_**
Diagnostic non-caseating granulomatas
**_X-ray_**
Enlarged lymph nodes
**_24h urine_**
Ca2+ increase.
**_Blood_**
Increased ESR, lymphopenia, LFT incerease,
Serum ACE increase
Increased Ca2+
115
What is the management of sarcoidosis?
Nothing usually
**_Corticosteroids_**
Prednisolone PO
116
WHAT IS IDIOPATHIC PULMONARY FIBROSIS?
Uknown excess amount of collagen in the lungs connective tissue and interstitial tissue after damage
117
What is the cause of IPF?
Uknown
118
What are the risk factors for IPF?
Old age
Smoking
Male
119
What are the different alveolar epithelial cells?
Type 1 and type 2 pneumocytes.
120
What happens when the alveoli lining is damaged in IPF?
Causes them to release transforming growth factor beta 1
Type 2 pneumocytes stimualte fibroblasts to turn into myofibroblasts
Myofibroblasts secrete reticular fibres and elastin fibres
Type of collagen with structural stregnth
Provide elasticity to lungs
Myofibroblasts then apoptose
121
What is the pathology of IPF?
Type 2 pneumocytes overproliferate
Too many myofibroblasts and too much collagen
No apoptosis
Even more collagen
Collagen accumulation
Thicker interstital
Problems with ventilation and oxygenation
122
What type of lung disease is IPF?
Restrictive
Interstitial lung disease
123
What happens with fluid in IPF?
Loss of alveoli and start pooling fluid
Seen as honeycombing
124
What are the symptoms of IPF?
4 D's!
Dry cough
Digital clubbing
Dyspnoea
Diffuse inspiatory crackles
125
What are the tests for IPF?
**_CXR_**
Thickening of alveoli walls
Honeycomb lung
_**Spirometry
**_Restrictive; decrease transfer factor.
**_Blood_**
ABG decrease in oxygen, increase in CO2
CRP increase; immunoglobulins increase;
ANA (30% +ve), rheumatoid factor (10% +ve).
**_BAL (Bronchoalveolar lavage)_**
126
What are the management options for idiopathic pulmonary fibrosis?
**_Supportive care_**
Oxygen, pulmonary rehabilitation, opiates, palliative care input
**_Antifibrotic medications_**
Pirfenidone and nintedanib
**_Lung transplant_**
127
WHAT ARE THE TWO TYPES OF LUNG TUMOUR?
Bronchial.
Pleural.
128
What are the different types of bronchial cancers?
**_Malignant (95%) = lung cancer_**
non small cell cancer
small cell cancer
**_Benign_**
hamartoma
carcinoid
lipoma
129
What are the causes of lung cancer?
Smoking
Asbestos
Chromium
Arsenic
130
What are the cell types of lung cancer?
**_Small cell lung cancer 15%_**
**_Non small cell lung cancer 85%_**
Squamous
Adenocarcinoma (adenocarcinoma-in situe)
Large cell 5%
NOS
131
What are the symptoms of local lung cancer?
Cough (40%)
Chest pain (20%)
Haemoptysis (7%)
132
What are the signs of lung cancer?
Weight loss
Anaemia
Clubbing
Supraclavicular or axillary nodes
133
What are the investigations for lung cancer?
CXR
Chest CT
Bronchoscopy
Needle or surgical biopsy
134
What are the sites of metastatic disease from lung cancer?
BBALL
Bone
Brain
Adrenal glands
Lymph glands
Liver
135
What is the treatment of lung cancers?
**_Stage I/II_**
surgical excision and radical deep x-ray therapy
**_Stage III/IV_**
Palliative chemotherapy, chemotherapy and radiotherapy, palliative care
136
WHAT IS MESOTHELIOMA?
https://www.youtube.com/watch?v=MMmjTbywMSI
Tumour of mesothelial cells in the pleura
137
What is the pathology of mesothelioma?
Epithelioid (Activated macrophages resembling epithelial cells)
Sarcomatoid (Sarcomatous, spindled or diffuse malignant fibrous mesothelioma)
Inflammation
DNA damage
138
What are the symptoms of mesothelioma?
FEVER
WEIGHT LOSS
FATIGUE
SOB
Persistent cough
Clubbed fingers
139
What are the tests for mesotheiomas?
**_CXR_**
Pleural thickening/effusion. Bloody pleural fluid
**_CT scan_**
**_Pleural aspiration_**
**_Biopsy_**
140
What is the treatment for mesotheliomas?
Symptom control
Palliative chemotherapy (Pemetrexed + cisplatin)
Radical surgery/debulking surgery
Palliative radiotherapy
141
What is type 1 respiratory failure? What is the cause?
Type 1: Low PaO2, normal (or low) paCO2, normal or high A-a gradient.
Limited of ventilation, perfusion or diffusion.
142
What is type 2 respiratory failure? What is the cause?
Type 2: low paO2, high CO2, usually normal A-a gradient (acute or chronic).
Alveolar hypoventilation.
CO2 enters alveoli, but not removed.
143
WHAT IS PNEUMONIA?
An infection in the lungs by microbes
Brings water into lung making it harder to breath
144
Who are the people at risk of pneumonia?
Infants and the elderly.
COPD and certain other chronic lung diseases.
Immunocompromised.
Nursing home residents.
Diabetes.
Alcoholics and intravenous drug users.
145
How can pneumonia be classified?
**_Bronchopneumonia_**
Throughout lung
**_Atypical_**
Interstatium
**_Lobar_**
146
What are the common microbes that cause pneumonia?
**_Viruses_**
Influenza
**_Bacteria_**
Strep pneumoniae
Staph aureus
Legionella's (hot country, air conditioning)
Jirovecci (HIV patients)
147
What is the pathogenesis of pneumonia?
Bacteria multiplies in the lungs, causes the lungs to become inflamed
Body releases chemicals to try and destroy the bacteria that cause inflammation
148
What are the symptoms of pneumonia?
Fever
Rigors
Fatigue
Pleuritic chest pain
SOB
Headache
Cough with sputum (rusty green)
149
What are the signs of pneumonia?
Pyrexia
Cyanosis
Tachypnoea
Drop in BP
SPUTUM
Confusion(esp. elderly)
150
How can you investigate if somebody has suspected pneumonia?
Listen to the chest
Gold standard
CXR
Consolidation.
**_Determine the causative organism_**
Sputum sample and blood culture
Urinary antigen test –Legionellas
Thoracentesis
151
How do you manage pneumonia?
Antibiotics for CAP:
Mild: oral amoxicillin
Moderate: oral amxoicillinand clarithromycin
Severe: IV co-amoxiclavand clarithromycin
Antibiotics for Legionellas:
Fluoroquinolone (ciprofloxacin) + clarithromycin
152
What is CURB-65?
Confused
Urea \>7
Resp rate \>30
Blood pressure 90/60
Over 65
153
WHAT IS ASTHMA?
REVERSIBLE chronic obstructive airway disease
154
What are the two main types of asthma?
Eosinophilic.
Associated with allergy.
Also non-allergic variant.
Non-eosinophilic.
155
What is asthma if not eosinophilic?
Overlaps with smoking and obesity.
156
What is often the cause of asthma?
**_Allergic_**
Genetics, environmental stimuli, hygiene hypothesis
**_Non-allergic_**
Intrinsic e.g. stress, cold air, infection
157
What is atopy?
Asthma
Hayever
Eczema
158
What happens when allergens from environment come into the body in asthma?
Dendritic cells present them to TH2 cells
Produce cytokines
IL4 (production of IGE, coat mast cells and release histamine)
and 5 (Eosinophils, Release more cytokines and leukotrienes)
159
What type of hypersensitivity is asthma?
Type 1 as it involves IgE
160
What happens in the airways of asthma?
Smooth muscle spasm
Increased mucus secretion
Airway inflammation
161
What are the symptoms of asthma?
Chest tightness
Coughing
Wheezing
Dyspnea
Sputum
162
What are the tests for asthma?
**_Spirometry_**
FEV1/FVC\<70% + Reversibility testing
**_Peak flow_**
(keep a diary –diurnal variation)
163
What are the differential diagnosis for asthma?
Bronchiectasis
CF
PE
Bronchial obstruction - foreign body, tumour, etc
Aspiration
COPD
164
What are the steps of treatment for chronic asthma?
**_Step 1_**
SABA (salbutamol)
**_Step 2_**
Beclametasone
**_Step 3_**
LABA (salmeterol) + Beclometasone
**_Step 4_**
Prednisolone
165
What is the treatment for an acute asthmatic?
Oxygen with nebulised SABA (salbutamol)
100mg hydrocortisone IV or 40-50mg prednisolone PO
166
WHAT IS TUBERCULOSIS CAUSED BY?
What is this bacteria?
Mycobacterium Tuberculosis
Which is an AEROBIC, NON-MOTILE SLIGHTLY CURVED ROD
167
What are the risk factors for TB?
Born in high prevalence area
IVDU Homeless
Alcoholic
Prisons
HIV+.
168
How is TB spread?
AIRBORNE DROPLETS
169
What are the different types of TB?
**_Healthy_**
Person has never been infected with TB
**_Active TB_**
This is when the bacterium are multiplying in the lungs and people have symptoms
**_Latent_**
The TB bacteria are NOT dividing in the lungs. Individual asymptomatic.
170
Where do the bacteria normally colonise in the lung?
Apex
171
What are the symptoms of TB?
Fever
Night sweats
Chills
Chest pain
172
What are the signs of TB?
Coughing up BLOOD
Individual will look unwell
173
How can you diagnose TB?
**_Sputum test (3x)_**
Used to detect acid fast organisms
**_Mantoux skin test_**
Latent TB
**_CXR_**
Enlarged lymph nodes
GOHN COMPLEX
**_CT scan_**
**_Ziehl–Neelsen stain_**
174
What is the treatment for active TB?
**_R_**ifampicin. 6 months
**_I_**soniazid. 6 months
**_P_**yrazinamide 2 months
**_E_**thambutol. 2 months
175
What are some side effects of RIPE?
**_Rifampicin_**
Red urine, hepatitis, drug interactions.
**_Isoniazid_**
Hepatitis, neuropathy
**_Pyranzidimide_**
Hepatitis, arthralgia / gout, rash.
**_Ethanbutol_**
Optic neuritis
176
WHAT IS PNEUMOTHORAX?
Build up of AIR in the pleural space
Sudden onset, sharp, one sided pleuritic chest pain and SOB
177
What are the causes of a pneumothorax?
**_Primary_**
No underlying lung disease, but risk factors include
MALE, SMOKING, FAMILY HISTORY, CONNECTIVE TISSUE DISEASE (Marfans, Ehlers Danlos).
**_Secondary_**
Underlying lung pathology that has caused it.
E.g. Trauma, fractured ribs, stab wound, gunshot, catheter, biopsy
178
What are the symptoms of a pneumothorax?
SOB
Sharp
ONE SIDED chest pain
Altered consciousness
179
What are the signs of a pneumothorax?
Low blood pressure
Low oxygen levels
Diminished breath sounds on the affected side
180
What are the tests for a pneumothorax?
**_CXR_**
BLACK
181
What are the management options for a pneumothorax?
Heal spontaneously
Treat the underlying cause, e.g. close the hole if there is an open wound causing it
Chest drain
Surgery
182
What is the emergency pneumothroax?
Tension pneumothorax
Thrachea deviation
183
How do you treat a tension pneumothorax?
Chest drain 2nd intercostal space
184
WHAT IS A PLEURAL EFFUSION?
What type of fluid can be there?
Fluid in the pleural space
Chyle, blood, serous, pus.
185
How can pleural effusions be divided?
**_Transudates_**
Excessive production of pleural fluid or resorption is reduced. E.g. heart failure, cirrhosis, nephrotic syndrome
**_Exudates_**
Result from damaged pleura. E.g. PE, bacterial pneumonia, cancer, viral infection, pancreatitis
186
What are the different names for blood in pleural splace etc?
Blood in the pleural space is a haemothorax, pus in the pleural space is an empyema, and chyle (lymph with fat) is a chylothorax.
Both blood and air in the pleural space is called a haemopneumothorax.
187
What are the symptoms of a pleural effusion?
SOB
Cough
Chest pain
188
What are the signs of a pleural effusion?
Decreased chest movement
Reduced breath sounds
Dull to percussion
189
What are the tests for a pleural effusion?
**_CXR_**
white (fluid),
**_Listen to the chest_**
Dull to percussion
Reduced breath sounds
**_Thoracocentesis_**
190
What are the management options for a pleural effusion?
Aspirate / chest drain
Pleurodesis
191
WHAT IS A PULMONARY EMBOLISM?
Where is it most commonly from?
Clot inside a pulmonary vessel
a DVT
192
What are the risk factors for a pulmonary embolism?
Immobility - \>3 days, surgery within last 4 weeks
Previous DVT/ PE
Pregnancy
Thrombophilic syndromes
Malignancy
Hormone Therapy
193
What are the symptoms of a pulmonary embolism?
Sudden onset dyspnoea
Chest pain
Red, swollen leg ?
Haemoptysis
Pre-syncope, syncope
Tachycardia
194
What are the signs of a pulmonary embolism?
Pyrecia
Cyanosis
Tachycardia
Tachypnoea
Hypertension
Raised jvp
195
What is Well's score?
What do the results show?
Clinical signs of PE/ DVT– 3
PE most likely diagnosis – 3
Tachycardic\>100 – 1.5
Immobility (\>3/7, surgery in last 4/52) – 1.5
Previous PE/ DVT– 1.5
Haemoptysis – 1
Malignancy +/- treated in last 6 months – 1
\<2 – PE unlikely
2-6 – moderate possiblity– do a D-Dimer
6+ - CTPA
196
What are the tests for a PE?
D-dimer – negative excludes PE but positive doe not prove it
If positive, need to do CT
197
What is the management of a PE?
Oxygen
Analgesia
**_Anticoagulation_** – LMWH, Fondoparinux
**_Start Warfarin_** – long term anticoagulation (Rivaroxaban is a suitable alternative)
Embelecetomy if large PE
198
WHAT IS GOODPASTURE'S SYNDROME?
Acute glomerulonephritis (blood in urine)
+ lung symptoms (haemoptysis/diffuse pulmonary haemorrhage)
199
What is goodpasture's syndrome caused by?
Antibodies form against type IV collagen
200
What type of sensitivty reaction is goodpastures syndrome?
Type 2
201
What are the environmental risk factors for goodpatures syndrome?
Smoking
Infection
Oxidative stress
202
What are the symptoms for goodpasture's syndrome?
**_Haemoptysis_**
SOB, chest pain, cough,
**_Haematuria_**
Proteinuria, oedema, uraemia, high bp
203
What are the tests for goodpasture's syndrome?
**_CXR_**
Infiltrates due to pulmonary haemorrhage, often in lower zones.
**_Kidney biopsy_**
Crescentic glomerulonephritis.
204
What are the treatment options for goodpasture's syndrome?
Treat shock
**_Immunosuppressive_**
Cyclophosphamide, prednisolone, rituximab
Plasmapheresis
205
WHAT IS WEGENER'S GRANULOMATOSIS?
https://www.youtube.com/watch?v=Ax98k35h\_jk
Small vessel vasculitis with caseating granulomas
206
What type of sensitivity is wegners?
Type 4
207
What parts of the body are affected in wegners?
Nasal passage
Respiratory tract
Kidneys
208
What are the features of wegener's granulomatosis?
**_Kidneys_**
RPGN with crescent cells
**_Lung_**
Migrating cavitatingcoin nodules, haemoptysis, pulmonary infiltrates
**_URT_**
Saddle nose deformity, epistaxis
**_Eyes_**
Iritis, scleritis, episcleritis
Arthritis
Elbow nodules
209
What antibodies are involved in wegners?
cANCAs
210
What are the tests for Wegener's granulomatosis?
**_cANCA_**
Raised
**_Urinalysis_**
Proteinuria or haematuria.
**_Biopsy of kidneys_**
Granulomas
**_CXR_**
Nodules ± fluffy infiltrates of pulmonary haemorrhage.
Increased ESR/CRP.
211
What is the treatment for wegener's granulomatosis?
**_Corticosteroids_**
**_Cyclophosphamide_**
Inhibit immune system
212
WHAT IS PULMONARY HYPERTENSION?
https://www.youtube.com/watch?v=Dx4QgdN\_hI4
Mean arterial blood pressure greater than 25 mmhg
213
What are the causes of pulmonary hypertension?
**_Pre-capillary_**
Multiple small PEs cause obliteration of vascular bed
Left-to-right shunts cause increased pulmonary blood flow and pressure
**_Capillary_**
Disease of pulmonary vascular bed
Eg emphysema, COPD
**_Post-capillary_**
Backlog of blood causes secondary pulmonary hypertension
LV failure
**_Chronic hypoxaemia_**
Living at high altitude
COPD
214
What are the symptoms of pulmonary hypertension?
Fatigue, pre-syncope
Tachycardia
Raised JVP
Altered heart sounds (louder S2)
Peripheral oedema – sacral, ankle
215
What is the diagnosis of pulmonary hypertension?
**_ECG_**
Increase pressure in pulmonary articles and right venticle
**_Spirometry_**
Chronic lung disease sometimes
216
What is the treatment for pulmonary hypertension?
Oxygen
**_Cardiogenic_**
Increase heart performance or decreease blood pressure
**_Phosphodiesterase-5 inhibitor_**
Viagra (sildeafil)
**_Prostacyclin analogue_**
Apoprostenol
217
WHAT IS CYSTIC FIBROSIS?
https://www.youtube.com/watch?v=BhFpFiZumS0
Excessive mucus build up in lungs and pancreas
218
What causes cystic fibrosis?
Autosomal recessive
CF transmembrane conductance regulator (CFTR) gene
Chromosome 7
DeltaF508
219
What is the pathophysiology of cystic fibrosis?
Defect in chlorine channel
Chlorine can therefore not be transported into the lumen.
Water does not move out by osmosis, making the mucus thick and sticky, clogging up the lumen.
Na+ also moves into the cells via an electrochemical gradient (Cl- is negative, Na+ is positive), which also draws water in with it and makes the mucus even more thick and sticky.
220
What can happen in newborns for cystic fibrosis?
Meconium - first stool
Can get stuck in intestine
Meconium ileus
221
How is pancreatic insufficiency caused in cystic fibrosis?
Thick secretions block the duct
No enzymes into intestine
Protein and fat not absorbed
Failure to thrive
Steatorrhoea
Pancreas damaged due to backup of enzymes
Localised inflammation - pancreastitis
222
What are the symptoms for cystic fibrosis?
Heavy mucus production, cough
223
What are the signs for cystic fibrosis?
Steatorrhea
Children with a failure to thrive
Finger clubbing
Rectal prolapse
224
What tests are done for cystic fibrosis?
90% diagnosed before the age of 8.
FAECAL ELASTASE
**_Sweat (NaCl) test_**
Parents taste salt when kissing baby
**_Genetics testing_**
DeltaF508
225
What are the management options for cystic fibrosis?
NO CURE, therefore symptom management
**_Non-pharmalogical_**
Physio for airway clearance
**_Pharmalogical_**
Antibiotics, anti-mucinolytics, bronchodilators, enzymes, insulin, bisphosphonates
**_Surgery_**
Lung transplant
226
What are the complications of CF?
INFERTILITY
Pancreatitis
RESP TRACT INFECTIONS
Bronchiectasis
