NEED TO WORK ON Flashcards
What are lung abscesses?
They occur in different cicumstances:
- Obstruction of the bronchus
- Aspiration
- Deposition of infection in the blood
What happens in bronchopneumonia?
The infection establishes in the small areas of the bronchi, the small bronchi and the bronchioles, and then spills over into the adjacent alveoli where we see pus, neutrophil polymorphs and inflammatory exudates fill there airspaces
How are the defences of the lung failing due to recurrent lung disease?
- Local bronchial obstruction - tumour or foreign body
- Local pulmonary damage - Bronchiectasis
- Generalised lung disease - cystic fibrosis
- Non respiratory disease - immunocompromised§
What is the pathological dilatation due to bronchiectasis due to?
- Severe infections
- Recurrent infections
- Proximal obstruction
- Surrounding lung tissue being destroyed
What is a very important risk during influenza in terms of morbidity and mortality?
Secondary bacterial infection
What are the main infectants of acute epiglottis?
- Haemophilus influenza
- Group a beta-haemolytic streptococci
What is Bronchiectasis 1?
Pathological dilatation of the bronchi to a size that is inappropriate for the position of the bronchi in the bronchial tree.
What are examples of opportunistic pathogens?
Low grade bacterial pathogens: CMV, Pneumocystitis jiroveci and other fungi and yeasts.
What is hypostatic pneumonia?
The localisation of the infectious process in the lower parts of the lungs and relates to other diseases like cardiac failure or COPD.
What is the macrophage-mucociliary escalator system?
Alveolar macrophages
Mucociliary escalator
Cough reflex
What can cause MMEs to fail?
Viral infections as it can lead to loss of cilia
What happens if the MMEs fail?
Anything inhaled is retained in the lungs
What is the cardiovascular clinical assessment for fitness for surgery?
- Angina
- Heart problems
- High blood pressure
- Smoking
- Stroke
- Heart murmurs
What cardiac assessments can be done for fitness for surgery?
- ECG
- ECHO
- CT SCAN
- ETT
What are the non fatal complications of lung cancer?
- Post thoracotomy wound pain
- Empyema
- Bronchopleural fistula
- Wound infection
What is the left laryngeal nerve notorious for?
It is notorious for being involved and destroyed by malignant lymph node processes in hilum of the left lung
Define parrafinoma.
- Injection of paraffin cause a tumefaction, usually a granuloma
How does circulatory shock happen after surgery?
The liver has an important role in removing fat soluble poisons from the blood stream and when a patient has cirrhosis, it is unable to do so and as a result it causes vasodilation and increased capillary permeability.
What blood tests can be used during the staging of lung cancer?
- Anaemia
- Abnormal LFTs
- Abnormal bone profile
What are the most common problems that are associated with the staging of lung cancer?
- Collapse of the lung or lobe makes tumour size difficult to assess
- Presence of another pulmonary nodule
- Retrosternal thyroid
- Adrenal nodule
What are the ways you can manage COPD?
- Prevention of disease progression (smoking cessation)
- Relieve breathlessness (inhalers)
- Prevention of exacerbations (vaccines)
- Management of complications (long term oxygen therapy)
What does the management of AECOPD involve?
- Short acting bronchodilators
- Steroids
- Antibiotics if there is evidence of infection
- Hospital admission if unwell
When are antibiotics used during COPD treatment?
If there is any evidence of the exacerbation being secondary to viral infection
What are other health effects of COPD?
- Loss of muscle mass
- Less drive to eat
What are the criteria to consider a hospital admission in COPD?
- Tachypnoea
- Hypotension
Why do people develop COPD?
- Reactive oxygen species causes tissue damage and deactivates proteases.
What are examples of high dose inhaled corticosteroids?
- Relvar
- Fostair
What ways are COPD patients managed in the wards?
Their oxygen saturation should be kept between 88-92%, they are given nebuliser bronchodilators, corticosteroids, antibiotics and they assess for evidence of respiratory failure.
What happens during progressive disease after primary infection?
Primary infection prgresses to TB bronchopneumonia, primary focus continues to enlarge, enlarged hilar lymph nodes compress bronchi, lobar collapse, enlarged lymph nodes discharged into bronchus, poor prognosis
How to identify TB?
- Sputum samples
- Induced sputum
- Bronchoscopy with BAL?
- Endobronchial ultrasound with a biopsy
How does TB affect the CSF and the pleura?
Causes meningeal TB and Tuberculosis pleural effusion
What is the result of activated macrophages?
- Damaged of epitheliod cells
- Langhans giant cells
- Accumulation of macrophages, epitheliod and Langhans cells
- Central ceseasting necrosis
What are the symptoms for post primary TB?
- Respiratory symptoms
- Felling unwell
- Malaise, night sweats, weight loss
What are the rules for TB treatment?
- Multiple drug therapy is essential
- Must continue for at least 6 months
- For committed specialists only
What are Th1 cells?
- Type 1 T helper cell produces interferon gamma, interleukin and tumour necrosis factors which activate macrophages and are responsible for cell mediated immunity and phagocyte dependent protective responses.
What is meant by the 2 edged sword of the Th1 mediated cells?
- Reduces the number of invading mycobacteria
What is a consequence of activated macrophages?
- Tissue destruction
What is the treatment for tuberculosis?
- Vitamin D
- Surgery
What is the Mantoux test?
- Injection of tuberculin into the transdermal layer of the skin, after 48-72 hours amount of induration present can identify possible health problems
What results in the duration in the Mantoux test?
- Intradermal administration of the tuberculoprotein, this results in macrophage based area of inflammation after 48 hours.
How do you screen for TB using tuberculoprotein?
If younger than 16 and no BCG there should be no immunity to tuberculoprotein.
What are the main side effects for treatment for TB?
- Hepatitis
- Rash
- Orange urine and tears
- Peripheral and optic neuropathy
- Gout
How would you treat a patient that is heaf positive exposed to TB?
- If the X-ray is normal then they are at risk of disease
- Chemoprophylaxis to kill mycobacteria
- Rifampicin and inhaled isoniazid for 3 months
- Inhaled isoniazid for 3 months
- If their X-ray is abnormal treat as primary TB
What stimulates macrophages to become activated?
Th1 helper cells which are activated by antigen presenting cells
What is the primary infection of TB?
- No preceding immunity or exposure, mycobacteria spread via lymphatics trading to hisar lymph nodes.There are usually no symptoms.
What are the drugs used for TB
Immunosuppressive drugs: isoniazid, pyrazinamide, rifampicin and Ethambutol
What does nitric oxide do?
It blunts the peripheral receptors response to falling alveolar partial pressure of oxygen, but it cant be used in chronic lung disease patients.
What happens when the partial pressure of carbon dioxide increased?
Carbon dioxide crosses the blood brain barrier not H+ which increases the [H+] in the cerebrospinal fluid which stimulates the central chemoreceptors which feeds the respiratory centres and leads to an increase in ventilation.
What is the difference in the presentation of SCLC and NSCLC?
Their presentations are identical but secretory syndromes are present
What is the treatment for SCLC in extensive disease?
- 4 cycles of chemotherapy
- Percutaneous coronary intervention: non surgical procedure which is used to treat narrowing of coronary arteries of the heart
- Single fraction radiotherapy
Who are TKIs used for?
- Patient who have a targetable mutations and people who have unfit for chemotherapy.
What are the side effects of radiotherapy?
- Lethargy
- Risk to surrounding organs
- Increased risk myocardial infarction
- 2nd malignancies
What are the features of bone pain for metastases?
- Occurs in any site
- Often worse at night
- There is a potential for pathological fracture
- Need for Palliative RT
When is a higher dose of palliative treatment used?
If the disease is too large to encompass radically and it has a survival advantage
What are the symptoms of pleural effusion?
- Asymptomatic
- Increasing breathlessness
- Pleuritic chest pain
- Malignancy
- Dull ache
- Dry cough
- Weight loss, night sweats , malaise
What are the main causes of transudate?
- Left ventricle failure, liver cirrhosis and renal failure
What are pulmonary blebs?
They are sub pleural thin walled air containing space that aren’t larger than 1-2cm in diameter. The walls are less than 1mm thick. If they upturn then air will escape into the pleural space resulting in a pneumothorax.
What is cyclothorax?
Lymph from the digestive system called chyle accumulates in the pleural cavity due to disruption or obstruction of the thoracic dict
What are the iatrogenic causes of a traumatic pneumothorax?
- Pleural aspiration, liver, lung, breast and renal biopsy
- Subclavian vein cannulation
- Acupuncture
How do you manage a secondary pneumothorax?
- Aspiration
- Intercostal chest drain - 4th intercostal space mid-axillary line
What are the two effects that are made from mast cell granule?
- Inducing inflammation by attracting a number if inflammatory cell types into the airways leading to swelling an oedema within the bronchial mucosa.
- Constriction of bronchial smooth muscle
What is acinus?
The gas exchange part of the lung
What is panaacinar acinus?
Takes out large areas of the lung
What are the main mechanisms of airway obstruction in COPD?
- Inflammation of the small airways leads to change in the smooth muscle tone.
- Emphysema loss of alveolar attachments
- Fibrosis - collapse of airways on expiration
What is pulmonary arteriolar vasoconstriction?
When alveolar tension falls it can be a localised effect, all vessels constrict if there is hyperaemia.
What is chronic cor pulmomale?
Pulmonary hypertension
Why do patients with hypoxic cor pulmonale get pulmoanry hypertension?
- Pulmonary vasoconstriction
- Pulmonary arterioles
- Loss of capillary bed
- Secondary polycythaemia
What is the result of anti trypsin deficiency?
Neutrophil elastase is free to break down elastin,
What is the main function of antitrypsin?
To protect the tissue from enzymes of inflammatory cells
What are the morphological changes in the large airways in chronic bronchitis?
Mucous gland and goblet cell hyperplasia
Inflammation and fibrosis
What are the morpholigcak changes in the small airways in chronic bronchitis?
Goblet cells appear
Inflammation and fibrosis in long standing disease
What is a secondary pulmonary lobule?
- The subsegment of the lung supplied by three to five terminal bronchioles separated by the adjacent secondary lobule by intervening connective tissue
What is a bronchial provocation test?
Evaluates how sensitive the airways in your lungs are. The spirometry results are compared before and after you inhale a spray (methacholine) to see what changes there are in your breathing
What are other useful investigations for asthma?
- Chest X-Ray
- Skin prick testing
- Total and specific IgE
- Full blood count
What is body mass index positively associated with?
Asthma, Wheezing, airway hyperactivity
Which diet substances affect risk of asthma?
- Decrease in anti oxidants and N-3 polyunsaturated fatty acids = risk factor.
- Increase in N-6 polyunsaturated fatty aids = risk factor.
- Too much or too little vitamin D
After confirmation of obstructed airways, what is your next step in the diagnosis of asthma?
Full pulmonary function tests, confirmation of reversibility with B2 agonists and steroids
If airways are not obstructed what is your next step in diagnosis?
Peak flow monitoring, Bronchial provocation with nitric oxide
What is the histopathology of hypersensitivity pneumonitis?
- immune complex mediated combined Type III and IV hypersensitivity reaction
- soft centriacinar epitheliod granulomatoma
- interstitial pneumonitis
- foamy histiocytes
- upper zone disease
When is there an imbalance in the ventilation/perfusion relationship?
When the pathology affects the small airways.
How is sarcoidosis diagnosed?
Mostly clinically but can be done with imaging
What are examples of a granulomatous chronic inflammatory response in the lung?
- Sarcoidosis
- Hypersensitvity Pneumonitis
What happens to the amount of elastic in interstitial lung disease?
Increases
What is an diffuse interstitial lung disease?
They are primarily inflammatory diseases affecting parenchymal part of the lung cause injury within the interstitium of the lung.
What is acute inflammatory response injury in the lung referred to as pathologically?
Diffuse alveolar damage
What is an important factor in interstitial lung disease with regards to the inflammatory process leading to fibrosis?
The more likely the process is to lead to fibrosis, the more likely the patient is going to have long term pulmonary difficulties.
What is the process of the development of DAD?
Over 1 or 2 days after injury the is a large amount of oedema that develops in the lungs because there is lots of damage to the interstitial of the lungs. Water and plasma proteins leak out and these plasma proteins precipitate on the alveoli forming hyaline membranes after several more days. It takes a few more days for the inflammatory process to develop and more days for fibrosis to follow on from the inflammatory process.
Why does sarcoidosis rarely proceed to significant fibrosis?
Because there are very little type III reaction or chronic inflammatory reactions.
What are the unifying features of lung disease?
- Involves interstitial part f the lung
- disease processes are diffuse on the lung involving much or all of both lungs
- they are also linked with restrictive lung defect on pulmonary function testing
What signs of CF does CT show?
Tramlines
Signet rings
Mucous plugging
Consolidation
What happens as a result of abnormal transport chloride and sodium?
Reduced airway surface liquid
Thick sticky mucous
Shearing
Impaired bacterial killing via neutrophils
How is haemoptysis different in CF?
This is due to bronchial wall destruction.
What do the new modulator drugs address?
CTFR production, processing, folding, transport and insertionq
What does a CTFR abnormality cause?
Abnormal electrolyte transport across cell membrane
Dehydration of airway surface layer (allows mucous to slide across airways and be coughed up)
Decreased mucociliary clearance
Mucous sticks to the mucosal surface and causes shearing damage
Increased bacterial adherence
Decreased bacterial killing
What organisms does sputum analysis indicate?
- Streptococcus pneumonia
- H influenzae
- Moraxella cattarhalis
What can you do if youre not sure if the patient has asthma?
Pulmonary function tests:
- Lung volumes: Increased residual volume and increased lung capacity (emphysema)
- transfer factor: reduced transfer factor (COPD rather than asthma)
What is secondary polycythaemia?
The body produces increased erythropoietin in response to low oxygen levels, Increases hemoglobin, increases hematocrit, increases blood viscosity.
What is the effect of gas trapping on lung volumes?
Increase in residual volume, Increase in total lung capacity, RV/TLC is greater than 30%
What are the signs of COPD?
Breathless walking in to clinic, undressing, Pursed lip breathing, accessory muscles, Cyanosis CO2 flap, Tremor (beta-agonists), Effects of steroids: tissue skin, bruising, Cushingoid, Hyperexpanded chest, Laryngeal descent, Paradoxical movement of ribs and abdomen, Decrease cardiac dullness to percussion
Decreases in breath sounds (no crackles) Prolonged expiration with wheeze, Palpable liver, Cor pulmonale: increased jugular venous pressure, hepatomegaly, ascites, oedema
What are the findings in carbon monoxide gas transfer?
Decreased gas transfer
(decreased TLCO which is the diffusing capacity for carbon monoxide)
Decreased KCO (KCO measures the integrity of the blood–gas barrier)
What will a chest radiograph show in COPD?
Hyperinflated lung fields, Flattened diaphragms, Lucent lung fields, Bullae
What does N1 refer to?
Ipsilateral peribronchial, hilar or intrapulmonary nodes including by direct extension
What does N2 refer to?
Ipsilateral mediastinal, sub carinal
What does N3 refer to?
Contralateral mediastinal, contralateral hilar, scalene or supraclavicular
What is M1a metastases?
Separate tumor nodules in a contralateral lobe.
What is M1?
Distant metastases in the thorax
What is M1b?
Single distant metastases
What is M1c?
Multiple distant metastases
What can a solitary pulmonary nodule be indicative of?
- lung cancer
- Metastases
- Bening lung neoplasm
- Vascular haematoma
What is EBUS?
Endobronchial ultrasound, Allows Doctor’s to look at the lungs and take samples from the glands in the mediastinum of the lung using the aid of an ultrasound scan, these glands lie outside the normal breathing tubes (bronchi). Ultrasound probe on the end of a bronchoscope allows the doctor to see the glands in the centre of the chest (mediastinum) and take samples under direct vision. Endobronchial ultrasound-guided transbronchial needle aspiration is done to take samples from the central lymph glands in the centre of your chest (mediastinum) which may be enlarged for a variety of reasons.
What is cogenital pulmonary airway malformation?
Abnormal non-function in lung tissues
What is the treatments for respiratory distress syndrome?
- Antenatal steroids
- Surfactant replacement
- Appropriate ventilation and nutrition
Where is remodelling seen?
Asthma and chronic lung disease of prematurity
What are the characteristics of remodelling?
- Increased bronchial responsiveness,
- Increase mucus secretions
- Airway oedema
- Airway narrowing
What happens when the carbon dioxide is passed into the lungs via the pulmonary circulation?
• The haemoglobin releases the hydrogen ions, That causes the bicarbonate to shift back into the blood cells to neutralise those hydrogens, carbonic anhydrase works in reverse to give carbon dioxide and water from the carbonic acid that has formed.
What influences oxygen diffusion between alveoli and blood?
Surface area and diffusion distance
What should you do with a severe asthma attack?
The patient should be in hospital.
They are now using nebulisers, Oral or IV steroids (faster onset), IV magnesium (doesnt make patients feel great), IV amophylline, trying to treat the triggers,
Complication (people who breath hard and hyperventilate are at a risk of getting pneumothorax.)
Level 2/3 care
What cells are responsible for the effects of asthma?
Th2 Cytokines, Eosonophils, mast cells
Give an example of an inhaled long acting anti-muscarinic?
Tiotropium Bromide
What is the effect of Mepolizumab?
Monoclonal antibody against interleukin 5
What are the two types of mismatch (ventilation-perfusion)?
- mismatch 1 (base) - Ventilation < Perfusion < 1
* Mismatch 2 (apex) - Ventilation > Perfusion > 1
Where does alveolar dead space occur to a small extent?
Apex of the lung.
What is the natural coping mechanism for alveolar dead space?
Pulmonary vasodilation and bronchial constriction
What are 7 signs that you expect to find on examination of someone with pneumoniae?
- Tachypnea - raised RR
- Tachycardia - increased HR > 90 bpm
- Reduced lung expansion
- Dull percussion note
- Bronchial breathing
- Crepitations (/snapping open of the alveoli)
- Vocal resonance increases
What are the three types of pneumonia?
Lobar, intersitial and bronchopneumonia
What are 7 symptoms of pneumonia?
- Fever
- Rigors (shivers)
- Myalgia (pain in the muscles)
- cough and sputum
- Chest pain
- Dysponea (breathlessness)
- Haemoptysis
What is bronchiectasis?
The dilation of bronchi producing sepsis in the chest
What are the signs of bronchiectasis?
Finger clubbing
Lung crackles on inspiration and expiratoin
What investigations are done for bronchiectasis?
Sputum culture
Spirometry
CXR
High resolution CXR are the main diagnostic tests
What are features of streptococcus pneumonia?
Abrupt onset High pyrexia/rigors Pleuritic chest pain Cough with purulent (green) sputum Hypotension and cyanosis Septicaemia
What is the treatment for streptococcus pneumonia?
IV benzyl penicillin, amoxicillin, oral ampicillin
What does the added sound of crackling usually indicate?
Infection
What are the main features of bronchiectasis?
Dilated and damaged bronchi
If the person is allergic to penicillin what antibiotics should be used?
Macrolide and Clarithromycin
What is the treatment for bronchiectasis?
Chest physiotherapy
Prompt treatment of infections with appropriate antibiotics ,
May require inhaled therapy including beta2 agonist and inhaled corticosteroid
What are the signs of pneumonia?
Pyrexia Tachpnoea Central cyanosis Dullness on percussion of affected lobe(s) Bronchial breath sounds Inspiratory crepitations Increased vocal resonance
What are 8 risk factors of pneumonia?
- Smoking
- Alcohol in excess
- Extremes of age
- Preceeding viral illnesses (flu)
- preexisting lung disease (COPD)
- Chronic illness
- Immunocompromised (HIV, CHEMOTHERAPY)
- Hospitalisation
- IV drug abusers
What are the potential complications of pneumonia?
Septicaemia Acute kidney injury Empyema Lung abscess Haemolytic anaemia ARDS
What is the treatment for empyema?
Chest drain, IV antibiotics
What does rusty brown sputum mean?
Streptococci pneumoniae
What are 6 investigations to carry out in hospital pneumonia?
Blood chemistry for the blood count, Full blood count, and an inflammatory marker called C reactive protein
- Blood cultures
- CXR
- Throat swab
- Sputum culture
- Legionella urinary antigen
What treatment is given to pneumonia patients?
Oxygen
I.V fluids
CPAP
Intubation and ventilation
What is shown in CXR of streptococcus pneumonia?
Classically lobar and often patchy shadowing
What organisms are more likely to result in cavitating pneumonia?
Staph. aureus, Pseudomonas, Anaerobes
What are the causes of Bronchiectasis?
Idiopathic Immotile Cilia Syndrome CF Childhood infections such as measles ABPA
What factors influence bulk flow of air between the atmosphere and the alveoli?
The difference between atmospheric pressure and alveolar pressure Airway resistance
Where are the two main stem cell populations in the lungs?
- Large arease of the bronchi
- Peripheral lung epithelium of the small bronchioles and the alveolar epithelium.
How does adenocarcinoma arise in the lung?
Bronchoalveolar epithelial stem cells transform
How does squamous cell carcinoma arise from?
Bronchial epithelial stem cells transform
What are other types of cancer that are found in the lungs?
- Carcinoid Tumour
- Tumours of bronchial glands
- Lymphoma
- Sarcoma
- Metastases from somewhere else to the lung
How does primary lung cancer grow?
It grows silently for many years, presents late in its natural history, may have few signs until the disease is very advanced. Symptomatic lung cancer is very fatal.
What are the local effects lung cancer?
- bronchial obstruction
- Pleural
- Direct invasion
- Mediastinum
- Lymph node metstases
What causes pancoat t1 damage?
Direct invasion to brachial plexus
What are small cell carcinoma characterised by?
Neuroendocrine differentiation
What are the therapy predicitve factors in lung cancer?
- Adenocarcinoma
- EGFR, KRAS, HER2, BRAF mutations
- ALK translocations, ROS1 translocations
- Squamous cell: little effective in molecular therapy
What oncogene is activated by smoking?
KRAS
What is an adenocarcinoma in situ?
Bronchioalveolar cell carcinoma
What are carcinoid tumours?
A carcinoid tumour is a rare cancer of the neuroendocrine system – the body system that produces hormones. The tumour usually grows in the bowels or appendix, but it can also be found in the stomach, pancreas, lung, breast, kidney, ovaries or testicles. It tends to grow very slowly
What is endogenous lipoid pneumonia?
when lipids enter the bronchial tree
What is horner’s syndrome?
Disruption of a nerve pathway from the brain to the face and eye on one side of the body. Typically, Horner syndrome results in a decreased pupil size, a drooping eyelid and decreased sweating on the affected side of your face.
What is used after the diagnosis to select patients for therapy?
Predictive biomarkers,
What is an immune checkpoint inhibitor?
A drug which prevents passage past a checkpoint, immune checkpoints control immune reactions
Give examples of how cancer cells avoid immune destruction
PD1, PD-L1
What are the adverse effects of ICS?
They have a height suppression (final adult height is reduced by 0.5cm to 1cm)
- If you don’t wash your teeth after using the brown inhaler you might get a bit of oral thrush.
- Supress ones own steroid production (highly uncommon with the brown inhaler, but purple and orange can)
- oral steroids can cause hypertension and cataracts, but inhaled ones don’t.
What is the treatment for patients for moderate acute asthma?
SABA via nebuliser + prednisolone
SABA and ipratropium via nebuliser and prednisolone
What are the treatments for patients with severe acute asthma?
IV salbutamol, IV aminophyline, IV magnesium, IV hydrocortisone, Intubate and Ventilate
What are the mechanics for wheeze?
Bronchoconstriction
Airway wall thickening
Luminal secretion
If the child has a cough what can it be indicative of?
–Bronchitis (2-3 year old, wet cough)
–Pertussis (any age, fits, vomit, haematoma)
–Habitual cough (8-12 year old, single loud cough)
–Tracheomalacia (life long loud cough
–Small print as per wheeze
What are the symptoms of bronchitis?
loose rattly cough started off with an URTI with an end of the cough there is vomit (post tussive vomit)
What are the infective agents of LRTIs
Virus and commensal bacteria/bacterium, mycoplasma, Chlamydia.
What is the treatment for tracheitis?
Augmentin
What is the peak incidence of bronchiolitis?
3 months
what is the cause of epiglottis?
Haemophilus influenzae
What are the causes of pulmonary hypertension
Idiopathic (1)
Secondary to left heart disease (2)
Secondary to chronic respiratoyr disease (3)
Chronic thromboembolic PH (4)
Miscellaneous (5): sarcoidosis, cogenital heart disease (left right shunt)
What are the symptoms of pulmonary hypertension?
Exertional breathlessness
Chest tightness
Exertional syncope (blackout) and presyncope (dizziness)
Haemoptysis
What are the signs of pulmonary hypertension?
Elevated Jugular venous pressure Right ventricular heave Loud pulmonary second heart sound Hepatomegaly Ankle oedema
What investigations are carried out for pulmonary hypertension?
ECG Lung function test Chest x-ray Echocardiography (ultrasound of heart) V/Q scandal Right heart catherisation
What is the D-dimer test?
Blood test of the product of clotting cascade of the blood
What are the indications for surgery in pneumothorax?
Recurrence
Persistence
after one episode of pneumothorax
What are bronchogenic cysts?
causes symptoms of pressing on trachea or oesophagus
What can cause lung abscesses?
Pneumonia
PTE
Lung cancer
Aspiration
What defines chronic ventilatory failure on arterial blood gas?
- Elevated PCO2
- PO2 < 8kPa
- Normal blood pH
- Elevated blood bicarbonate
what are the main examples of chronic ventilatory failure?
Airways disease
Chest wall abnormalities
Respiratory muscle weakness
Central hypoventilation
What respiratory muscle weakness conditions result in chronic respiratory failure?
- motor neurone disease
- Muscular dystrophy
- glycogen storage disease
What are examination findings of chronic ventilatory failure?
Paradoxical abdominal movement
Ankle oedema
What investigations are carried out for chronic ventilatory failure?
- Lung function
- Assessment of hypoventilation
- Fluoroscopic screening of diaphragm
what lung function investigations are carried out during chronic ventilatory failure?
Lying and standing vital capacity
Mouth pressure/sniff nasal inspiratory pressure
What test would be done for the assessment of hypoventilation in chronic ventilation failure?
Early morning Arterial blood gas
Overnight oximetry
Transcutaneous CO2 monitoring
What is the treatment for chronic ventilatory failure?
Domicilary non invasive ventilation
Oxygen therapy
How is obstructive sleep apnoea syndrome diagnosed?
- History and examination
- Epworth questionarre
- Overnight sleep study
How is obstructive sleep apnoea treated?
- Identifying exacerbating factors
- Continuous positive airways pressure
- Malibu are repositioning splint
What is the treatment for Narcolepsy?
Modafinil
Dexamphetamine
Venlafaxine (for cataplexy)
Sodium oxybate (xylem)
What are anatomical causes of restriction?
Lung Pleura Muscle Bone Other
What are skeletal causes of restriction?
Kyphoscoliosis
Ankylosis spondylitis
Thoracoplasty
Rib fractures
What are muscular causes of restriction?
Amyotrophic lateral sclerosis
What is the shitologivsl hallmark for sarcoidosis?
Non caseating granuloma
How do you investigate restrictive lung disease?
History and examination CXR Pulmonary function tests Bloods Urine analysis Eye exam
What do you see in CXR of sarcoidosis?
Enlarged glands
How is erythema nodosum treated from sarcoidosis?
NSAIDS
What drugs can be used to slow down the lung fibrosis in idiopathic pulmonary fibrosis?
Oral anti-fibrotic
Pirnfenidone
Nintedanib
Palliative care
What four abnormal states are associated with hypoxaemia?
Ventilation perfusion imbalance
Diffusion impairment
Alveolar hypoventilation
Shunt
What diseases can cause pathological shunt?
Arterial-venous malformations, congenital heart disease and pulmonary disease.
In pneumonia, why do patients have hypoxaemia?
- Ventilation/perfusion mismatch
- Shunt
Why do people get alveolar hypoventilation?
Upper airway and trachea obstruction
Mechanical problems with breathing mechanism
Functional problems with breathing mechanism
Neurological problems with breathing mechanism
Why might a patient with COPD have hypoxaemia?
Ventilation perfusion imbalance
Diffusion impairment
Alveolar hypoventilation
Shunt
What happens in fibrotic lung disease?
There is a thickened alveolar membrane due to the build up of fibrous tissue under the connective tissue and elastic tissue of the lungs and it also ends up forming in between the type I alveolar cells and the type II alveolar cells and this slows gas exchange. There is also a loss in compliance which may decrease alveolar ventilation. The partial pressure for oxygen then falls and there is a lower partial pressure gradient and so less oxygen goes into the blood.
What is defined as life-threatening asthma?
Any one of: Altered conscious level, Exhaustion, Arrythmia, Hypotension, Cyanosis, Silent chest, poor respiratory effort, PEF < 33% best or predicted, SpO2 < 92%, PaO2 < 8kPa, normal PaCO2
What is the concentration of haemoglobin in the blood?
150 g/L
What are the paraneoplastic symptoms of advanced disease?
- Hyponatraemia
- Anaemia
- Hypercalcaemia: Parathyroid hormone related protein and Bone metastases
- Dermatomyitis/Polymyositis: Proximal muscle weakness
- Eaton Lambert Syndrome: Upper limb weakness
- Cerebellar ataxia
Sensorimotor neuropathy
What are the clinical signs of lung cancer?
- Chest signs
- Clubbing
- Lymphadenopathy
- Horners Syndrome
- Pancoast tumour
- Superior vena cava obstruction
- Lymphadenopathy
- Hepatomegaly
- Skin nodules
What are treatment decisions for lung cancer?
- Performance status
- Patient wishes
- Histological type and stage
- Multidisciplinary team
- Aims of treatment
What is palliative management during lung cancer?
- Symptom control (chemo, radiotherapy,
- Quality of life
- Community support
- Decisions and planning, resuscitation status, end of life care
Which types of lung cancer have high associations with smoking?
Squamous cell and small cell carcinoma
What is neutropaenic sepsis?
It is the most life threatening of chemo, neutrophils are low, treated with urgent admission, IV fluids and antibiotics
What type of respiratory failure does a patient with PE have?
Type 1 respiratory failure: low paO2 with normal or low CO2
What would an arterial blood gas for a patient with a PE show?
Respiratory alkalosis
The immediate inflammatory phase of asthma is an example of which type of hypersensitivity reaction?
A type I hypersensitivity reaction is caused by reaction to an allergen, as seen by the triggers in asthma.
What type of respiratory failure is found in mild to moderate asthma?
Type I because there is a decreased partial pressure of both oxygen and carbon dioxide.
What type of respiratory failure takes place in near-fatal asthma?
Type II respiratory failure - more extensive involvement of the airways and so oxygen cant be breathed in and so there is a decreased PO2 and an increased PCO2
Why is the dry cough associated with asthma more common at night?
The vagus nerve is more active at night.
Which type of antibody causes mast cell degranulation in asthma?
IgE
What type of pattern of asthma is seen in spirometry of someone with asthma?
Obstructive
What are the symptoms of near-fatal asthma?
Raised PaCO2 and mechanical ventilation
If a patient is hypercapnic after being diagnosed with an acute exacerbation what is the next management step?
Refer to the intensive treatment unit - the patient is acutely unwell and this is shown by the hypercapnea, this leads to respiratory acidosis and other complications.
By which mechanism does chronic bronchitis cause damage to the lungs?
Inflammation of the airways causes a hypersecretion of mucus
As part of the disease process, what kind of cell replace the ciliated cells that should normally line the respiratory tract?
These goblet cells cause increased stasis of mucus, of which there is also hypersecretion.
Which of the following imaging methods is most commonly used to help form a diagnosis of Chronic Obstructive Pulmonary Disease (COPD)? (1 mark)
Chest X-Ray
By which mechanism does emphysema cause damage to the lungs?
Breakdown of elastase
Which symptom is most commonly the first to appear in Chronic Obstructive Pulmonary Disease (COPD)?
A cough that is worse in the mornings
Which organism causes bronchiolitis?
Respiratory synctial virus
Describe CURB 65.
C - confusion U - Urea < 7mmol R - Respiratory rate > 25 B - Blood pressure: < 90/60 65 = older than 65 years of age
What is a classical sign of pneumonia on the chest radiograph?
Shadowing on the infected area
What CURB score requires admission to hospital?
> 2
What CURB score required admission to the intensive care unit?
> 4
What condition makes it more likely for a person to get aspiration pneumonia?
Multiple sclerosis - neurological condition so may cause a defective swallowing mechanism
What is the correct definition of hospital acquired pneumonia?
Pneumonia that has occurred over 48 hours after admission and was not incubating at the time of admission
What are the two most common organisms that result in community acquired pneumonia?
Haemophilus and streptococcus
In which group of people is bronchitis usually diagnosed?
Smokers
What three conditions make up Young’s syndrome?
bronchiectasis, sinusitis, reduced fertility in men.
What makes up Kartegeners syndrome?
bronchiectasis, sinusitis and situs inversus
What is test is used to diagnose bronchiectasis?
CT scan
What test is used to diagnose Cystic fibrosis?
- Sweat test
- Newborn heelprick test
Which condition is seen in approximately 1 in 5 new-borns with cystic fibrosis?
Meconium ileus - In this condition the bowel is blocked with sticky secretions, causing signs of obstruction soon after birth
What are the 3 most common symptoms of bronchiectasis?
chronic cough, breathlessness on exertion and daily sputum
What symptom isn’t so common in bronchiectasis?
Wheeze
What is the correct definition of an acute exacerbation of bronchiectasis?
Acute exacerbation of bronchiectasis is a deterioration in three or more key symptoms for at least 48 hours.
What is the MRC dysponea scale?
1 - Normal
2 - Able to keep up with people of similar age but not on hills or stairs
3 - Able to walk 1.5km on the same level, but unable to keep up with people of same age
4 - Able to walk 100m on the level
5 - Breathless at rest or minimal effort
Which MRC scores would be suitable for pulmonary rehabilitations?
3, 4
Will the primary complex always calcify once a primary tuberculosis infection has healed?
No, not in every patient
Why must vitamin B6 be taken with tuberculosis treatment?
Vitamin B6 can help prevent the peripheral nerve damage that can be caused by isoniazid.
What are risk factors of tuberculosis?
- Travelling to an area of high infection rate
- Being in contact with people who originate in areas with high infection rates
- immunocompromisation
What is the primary complex?
The primary complex is the primary focus (the sub-pleural collection of tubercles) and the hilar lymph nodes that drain this area.
What is the standard treatment for tuberculosis?
In the standard treatment pathway for tuberculosis, rifampicin and isoniazid are taken for six months, with pyrazinamide and ethambutol taken as well for the first three months.
How is tuberculosis spread?
Tuberculosis is spread through droplet transmission, meaning that being around an infected patient who coughs, or sneezes is the highest risk.
What is a tubercle?
spherical granuloma with central caseation, caused by the macrophages ingesting Mycobacterium tuberculosis.
Where does reactivation of latent tuberculosis most commonly occur?
In the lungs
Where should a cannula be inserted for a tension pneumothorax?
2nd intercostal space, mid clavicular line
Give an example of an exudative cause of pleural effusion?
Malignancy
What will happen to vocal resonance when examining a patient with a pleural effusion?
Vocal resonance would be decreased in a patient with a pleural effusion because the sound does not travel as well through the fluid as the air.
Give an example of a transudative cause of pleural effusion?
Pulmonary hypertension
What is the position of a normal chest drain?
5th intercostal space, mid axillary line
What occurs in a tension pneumothorax but not a spontaneous pneumothorax?
Tracheal deviation
When should malignancy be considered for a cough?
A new persisting cough for more than three weeks
What is the likely course of management for stage IV metastatic lung cancer?
Stage IV metastatic lung cancer has a very low survival rate even with interventions like surgery, radiotherapy or chemotherapy. This means that this patient is most likely to be offered palliative management, focused on comfort and symptom relief rather than cure.
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What are the most common types of lung cancer?
Adenocarcinoma and squamous cell carcinoma
Describe development of the respiratory system.
(Pseudoglandular stage) Week 8 - 16: development of the conduting potion of the respiratory system
(Canalicular stage) Week 16 - 26: development of the respiratory bronchioles
(Terminal sac) Week 26 to Term: development of the alveoli and type 1 & 2 pneumocytes
What drugs are given to pregnant women to help produce surfactant?
Glucocorticoids should be given to women in preterm labour to encourage surfactant development in the fetal lungs.
What type of molecule is surfactant??
Lipoprotein
is surface tension lower or higher for smaller alveoli?
Lower
What happens to surface tension as radius increases?
It increases
What factors affect how air flows through the respiratory system?
Radius of the airway
If the air is laminar or turbulent
What two diseases can alpha 1 antitrypsin deficiency lead to?
Emphysema and cirrhosis
What kind of chest is found in emphysema ?
Barrell chest
What infections can cause interstitial lung disease?
Tuberculosis and aspergillosis
What are the clinical signs of Interstitial lung disease?
Reduced chest expansion and increased RR
What is the definition of the total lung volume?
the volume of air present in the lungs after maximal inspiration.
When a patient develops interstitial lung disease, what happens to the compliance and the elastic recoil of the lungs?
Compliance decreased and elastic recoil increases
When a patient develops emphysema, what happens to the compliance and the elastic recoil of the lungs?
In emphysema, the elastin fibres are broken down resulting in the lungs having less pull inwards, so the compliance (ability of the lungs to expand) is increased. The elastic recoil of the lungs is decreased secondary to the loss of elastic fibres.
What is the normal haemoglobin concentration?
2.2 mmol/L
What two things determine the partial pressure of oxygen?
The rate at which oxygen diffuses into the blood and the rate at which the oxygen is replenished by ventilation.
