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