Pulmo Flashcards
Define the 3 different types of pneumonia and differentiate between atypical and typical pneumonia .
Community acquired
Hospital acquired >48 hrs after admission
Aspiration pneumonia
Typical
- classic symptoms
- typical findings on exam
- Lobar or bronchopneumonia
Atypical
- less distinct symptoms ( no chills, low fever )
- unremarkable exam
- interstitial pneumonia ok X-ray
Risk factors for pneumonia
Age COPD , asthma , CF Smoking Immunocomprimised Season
Classical symptoms of pneumonia
Fever SoB Rigors, ache Productive cough Pleuritic chest pain
Signs of pneumonia
Fever Tachypnoea Crackles Cyanosis Dullness on percussion Bronchial breathing
Leukocytosis
High CRP
Infiltrate on X-ray
What’s the most common organism causing pneumonia in the community?
And others ?
Streptococcus pneumonia
H. Influenza
M. Cartarrhalis
Name 3 atypical organisms that cause pneumonia in the community
Mycoplasma pneumonia
Chlamydia
Legionella
Give 4 organisms causing hospital acquired pneumonia
Klebsiella
Gram - e.g pseudomonas , enterobacteriae
Staphylococcus aureus
Streptococcus pneumonia
Is what type of bacteria?
What are is features ?
Gram + diplococci
Lobar consolidation
Usually penicillin sensitive
Rusty sputum
Often preceeded viral infection
Which organism is most commonly responsible for COPD excacerbation
H influenza
Gram - rods
Which organism causes pus formation in pneumonia and commonly leads to complications?
Staphylococcus aureus
Gram + cocci
Name a organism that causes pneumonia in CF patients
Pseudomonas aeruginosa
Which score is used to classify severity of pneumonia and treatment indications ?
CURB 65
Confusion , urea >7, RR >30 , BP <90 , age > 65
One point for each
0-1 - mild and home treatment
2 - hospital treatment
3-5 severe , consider ICU
Give 2 types of pneumonia that you could expect in an immunocomprimised patient !
Think opportunistic !
Pneumocystis jiroveci
Aspergillus fumigates
Explain the classic triad of pneumonia
- Evidence of infection (fever, chills, leukocytosis )
- Signs / symptoms localised to respiratory tract ( cough, sob, low 02, high RR)
- New / changed infiltrates on X-ray
What’s the treatment of community acquired pneumonia ?
Penicillin + macrolide
E.g benzilpenicillin / amoxicillin
+ clarithromycin / azithromicin/ erythromycin
Oral ( combine and IV if moderate )
For 5-7 days
Penicillin allergy : cephalosporin e.g cefuroxime
Complications of pneumonia
Empyema Pleural effusion Lung abscess Respiratory failure Myocarditis , pericarditis Cholestasis AF Sepsis
Prevention of pneumonia
Stop smoking
Pneumococccus vaccination and influenza vaccination in immunocomprimised and old people and if COPD or other chronic conditions
C/I pregnancy
What is bronchiectasis and what are the causes ?
Abnormal dilatation of bronchi and bronchioles , irreversible + thinning of these airways
CF Kartegeners sydrome Young syndrome Primary ciliary dyskinesia Chronic infections - pneumonia HIV, TB obstruction with tumour or foreign most Allergic bronchopulmonary aspergillosis RA Chrohns
Which pathogens are commonly associated with bronchiectasis ?
Staph aureus
H influenzae
Strep pneumonia
Pseudomonas
Classical features of bronchiectasis
Persistent chronic cough Lots of mucopurulent ( fouly smelling ) sputum Unpleasant breath feotor Cyanosis Clubbing
Which test would you perform to confirm bronchiectasis ?
And what does it show ?
CT
Signet ring sign (thick bronchus wall, lumen wider than vessel)
How to manage bronchiectasis ?
Airway clearance techniques ( Physiotherapie ) Smoking cessation Vaccinations AB if excacerbation Bronchodilators
What is cystic fibrosis and what is it causes by?
Autosomal recessive
Multi system condition
Mutation in CFTR ( cystic fibrosis transmembrane conductance regulator ) gene ( chromosome 7)
-> abnormal iron transport across chloride channels
Explain the effects of cystic fibrosis on multiple organs
Lungs :
Recurrent chest infections (impaired ciliary function, retention of secretions )
Pancreas :
Malabsorption , steatorrhea
Failure to thrive ( ducts blocked by thick secretions )
Intestine :
Meconium ileus in neonates ( thick viscous meconium production )
Sweat glands
High Na and Cl in sweat
How to diagnose CF?
Sweat test
High chloride
Gene testing
CFTR Gene
How to manage a patient with cystic fibrosis ?
Multidisciplinary
Lung - Physio - monitor via sporometry - prophylactic antibiotics Eg flucoxacillin If pseudomonas : ciprofloxacin, gentamicin, ceftazidime
Nutritional
Pancreatic enzyme replacement
High calorie diet
Vitamins EDKA
Complications of cystic fibrosis in adults
Diabetes mellitus
Liver disease ( cirrhosis )
Distal intestinal obstruction
Infertility in men
What is acute respiratory distress syndrome ?
What is it causes by ?
It’s an acute injury to the lung either directly or due to systemic illness
Pulmonary
- pneumonia
- Inhalation
- contusion
Other
- multiple transfusions
- sepsis
- shock
- malaria
- drugs : Aspirin, Heroin
- pancreatitis
- liver failure
- haemorrhage
Explain how injury can lead to ARDS ?
What are the clinical features of ARDS?
Lung damage -> release of inflammatory mediators -> increased capillary permeability & non-cardiogenic pulmonary oedema
Dyspnoea
Cynoasis
Bilateral crackles
Peripheral vasodilation
Which 4 diagnostic criteria have to be present in order to diagnose ARDS ?
- Acute onset
- High oxygen demand with refractory hypoxia
- Lack of clinical congestive heart failure / PCWP < 19 mmHg
- Bilateral infiltrates on X-ray
A patient presents with haemoptysis , a long history of smoking and weight loss and anorexia .
Most likely diagnosis ?
Lung cancer
DD: tuberculosis
Patient presents with pink frothy haemoptysis , disponier and bibasal crackles heart on examination .
Most likely diagnosis ?
Pulmonary oedema
A patient presents with pleuritic chest pain, tachycardia , tachypnoea and haemoptysis .
What could be a DD?
Pulmonary embolism
Patient presents with history of purulent , persistent cough and now haemoptysis . Likely diagnosis ?
Lower respiratory tract infection
If chronic and lots of purulent sputum think bronchiectasis
A patient has a history of tuberculosis 8 years ago. He know presents with haemoptysis and the x rays shows rounded opacity
Aspergilloma
Fungi in pre excisting cavity
Patients presents systemically unwell with haemoptysis , haematuria + hypertension + acute kidney failure .
What’s the diagnosis ?
Goodpasture syndrome
( anti GBM disease )
Lung + glomerulonephritis
A patient with AF presents with a Malar flush on his cheeks, a mid-diastolic murmur , dyspnoea and haemoptysis .
Likely diagnosis ?
Mitral stenosis
A patient with a saddle nose deformity presents with a lower respiratory tract infection with haemoptysis ,sinusitis and glomerulonephritis.
What’s the diagnosis ?
Granulomatosis with
Polyangiits
= Wegeners disease
Define pulmonary hypertension
Mean pulmonary artery pressure > 25 mmHg at rest
Normal = 10-14
Chronic pulmonary hypertension can cause ?
Cor pulmonale
Right heart dilatation / hypertrophy and failure
Causes of acute and chronic cor pulmonale
Acute usually causes bei Pulmonary embolism
Chronic
-COPD, asthma, lung fibrosis eg interstitial lung disease ,
-PE, pulmonary vasculitis , ARDS, primary pulmonary hypertension ,
Sickle cell.
- neurology: myasthenia gravis, motor neuron disease ,
- sleep apnoea
- kyphosis, scoliosis
Symptoms of cor pulmonale
Asymptomatic
Fatigues , dyspnoea on excretion Tachycardia Arrhythmia Right hear failure : - peripheral oedema - raised JVP - hepatomegaly - raised BNP -palpitations -graham steel murmur -parasternal heave
Which investigation can indicate cor pulmonale ?
ABG: hypoxia +- hypercapnia
ECG right heart hyperteophy -> right axis deviation , S1 Q3 T3 P-pulmonale ( high p wave ) RBBB Tachycardia Arrhythmia
Chest x ray
- produced pulmonary arteries
- right heart hyperteophy
- signs of underlying disease
Echo - hyperteophy
Confirmatory test : right heart catheter and then measure pressure
What type of hypersensitivity reaction is allergic asthma ?
Type 1 hypersensitivity
IgE mediated
Name the two types of asthma and their causes .
Extrinsic / allergic asthma
- develops typically in childhood
- biggest risk factor : atopy
- environmental : Pollen, animals , mould
- dust
Intrinsic / non allergic asthma
- cold air
- develops late > 40
- exercise induced
- gastric reflux
- stress
- irritants like smoke
- Aspirin !!
Asthma is caused by airway narrowing. Which factors contribute to that?
Bronchial muscle contraction
Mucosal swelling & inflammation
- Mast cell degeneration with inflammatory mediator release
Increased mucous production
—> bronchial hyperreaponsiveness
Classical symptoms of asthma
Wheeze Dyspnoea Dry cough, worse at night and with exercise and exposure Allergic rhinitis Chest tightness
You are examining a patient with asthma . What are your findings?
Hyperinflation of chest
Wheeze ( polymorph ) end expiration
Hyperresonant on percussion
Reduced PEFR
Typical spirometry findings of patients with asthma
Obstructive pattern
Decrease FEV1/FVC RATIO < 70% !!!
Low FEV1 -> 15% improvement after salbutamol inhalation
( reversible obstruction )
Normal FVC
Explain general measures as well as pharmacological
Options in asthma therapy
- avoid triggers
- quit smoking
- teach / monitor inhaler technique , PEFR
- written action plan
- SABA salbutamol + ICS ( eg beclomethasone 200 mcg / day)
- Add LABA salmeterol
3 stop LABA and increase ICS or leave LABA and increase ICS
Trial of theophylline, LAMA - Trial of ICS high dose
Add 4th drug : Leukotriene recep antagonis, b-agonist, LAMA
5 oral prednisone
A asthmatic patient becomes pregnant . What is Important to advice her in terms of her medication?
inhales drugs
Theophylline and presnisolone are all safe in pregnancy and breast feeding
Side effects of salbutamol ?
SHORT ACTING B AGONIST
- tremor
- hypokalaemia
- hyperglycaemia
Give an example for inhaled steroids and their Side effects
Beclomethasone
Fluticasone
Budesonide
- oral candidiasis
- stunted growth in children
How does patient with acute asthma attack present?
Unable to complete sentences
Tachycardia
Tachypnoea
Life threatening : silent chest
How to treat acute severe asthma ?
Salbutamol 5mg nebulised \+ Oxygen high flow \+ Prednisolone 30mg PO
Causes of COPD
Smoking Passive smoking Alpha antitrypsin decifiency Asbestosis Occupation with fine dust
Classical symptoms & signs of COPD
Productive cough Dyspnoea Cyanosis / tachypnoea / tachycardia Weight loss Clubbing Crackles and where Hyperinflation
COPD can be classified into 4 stages . How?
By FEV1 (of predicted )
- Mild - > 80%
- Moderate 50-79 %
- Severe 30-49%
- Very severe <30%
How to investigate a patient with COPD and what do the tests show ?
Spirometry
- obstructive , non reversible
- FEV1/FVC ratio < 70%
- FEV1 < 80
- high TLC
- high residual volume
Chest X-ray
- -> hyperinflation
- flattened diaphragm
- horizontal ribs
- increased intercostal space
- increase retrosternal space
FBC
- check for secondary polycythaemia (hypoxia increases EPO)
- -> high Hb, red cell count and PCV packed cell volume
BGA
Hypoxia or type 2 respiratory failure
Management of COPD
- General : smoking cessation , vaccination ( influenza, pneumococcal) , physical activity
- Bronchodilators
SABA OR SAMA - FEV1 > 50 LAMA or LABA
FEV1 < 50 LAMA OR LABA + ICS - If LABA switch to LABA + ICS
Or LAMA+LABA+ICS
How to treat a acute excacerbation of asthma ?
Nebulised salbutamol + ipatropium
Controlled oxygen therapy
( if hypercapnic only up to 88-92% )
if unresponsive
IV hydrocortisone or oral presnisolone
Antibiotics
Eg amoxicillin or clarythromicin
Define hypoxia
PaO2 < 8 kPa
Explain the two types of respiratory failure and it’s causes
Type 1
Hypoxia plus normal or low Ca02
Cause : Ventilation - perfusion mismatch (-> impaired gas exchange due to consolidation of lung )
Eg Pneumonia, PE. Pulmonary oedema , fibrosis , Asthma
Type 2 Hypoxia and hypercapnia Due to hypoperfusion - asthma, COPD , pneumonia , obstructive sleep apnoea - sedative drugs , tumour , trauma - GBS, myasthenia gravis - kyphoscoliosis
A patient underwent hip replacement surgery. On the Ward he presents with sudden onset dyspnoea , pleuritic chest pain and haemoptysis .
What’s the diagnosis ?
Pulmonary embolism
Risk factors for pulmonary embolism
Surgery , esp bone , pelvic, abdominal Leg fractures Prolonged bed rest / reduced Mobility Pregnancy / pill/ post partum/ HRT Thrombophilia
Signs of pulmonary embolism
Hypotension Tachycardia Tachypnoea Cyanosis Raises JVP Pleural effusion Pleural rub
DVT - swollen leg
What investigations would you run in a patient with suspected pulmonary embolism ?
Bloods
-> D-Dimer ( - results exclude diagnosis )
ECG
Maybe normal , tachycardia (sinus)
Sometimes AF
Chest X-ray
Normal ,
Small effusion can show blunted costophrenic angle , linear atelectasis
CT angiography
Shows emboli in arteries
Treatment of pulmonary embolism
- oxygen
- LMW heparin followed by warfarin
If massive : thrombolysis with altepase
(Analgesia, fluids )
Prevention of PE
Ted stockings
Early mobilisation
S.c LMW heparin e.g Dalteparin 2500 units / 24 hrs
Which score assesses risk of DVT and therefor PE ?
Wells score
Which people are at risk of asbestos exposure ?
Shipyard worker at the docks
Industrial worker
Fire fighter
Construction worker
What can asbestos cause ? What is it a risk factor for?
Risk factor for lung cancer
Can cause
pleural plaques
Pleural thickening
Asbestosis (fibrosis )
mesothelioma (pleural cancer )
Which organ does the myobacterium tuberculosis most commonly affect ?
Which type of bacteria is it ?
The lungs
Gram +
Acid fast bacilli , survives in gastric acid
How may a patient with suspected TB present with?
In acute: Productive cough and haemoptysis Exertional dyspnoea Night sweats Low fever
If not acute probably asymptomatic
Name the biggest risk factor for getting TB?
Think the 4 As
HIV
Immunosuppression
Ausland
Armut
AIDS
Alkohol
What would you find in a patient with active / primary TB?
The primary complex
= caseous granuloma
+
mediastinal Lymph nodes
What happens in latent TB?
There has been a prior infection but bacterium stays ( can get deactivates )
+ quantiferon test
But NO CURRENT infection
What happens in reactive TB?
Reactivation of bacterium due to
Immune down regulation e.g chemo
In an severely immunocomprimised patient with tuberculosis , which sepsis can occur ?
Landouzy sepsis
What is an open TB?
When cavitations are connected to bronchus !
Classical X-ray findings
Of a patient with TB
Finronodular linear opacities ( upper lobe)
Cavitations
Caseous granuloma
Miliary disease ( all over lung )
Which tests could you perform in a patient with suspected TB?
Quantiferon test ( Interferon Gamma release test ) ( which is - in vaccinated people)
Tuberculin skin test
Treatment of tuberculosis
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
Differentiate between the different types of pleural effusions
Transudate
( protein <25g /L )
Exudate
( protein > 35 g/L)
What are causes for transudate pleural effusion?
Cardiac failure Fluid overload Hypoproteinuria (cirrhosis nephrotic syndrome) Hypothyroidism Meigs syndrome
What are causes for exudate pleural effusion ?
Pneumonia TB Pulmonary infarction RA SLE Carcinoma Metastasis Mesothelioma
Investigations of pleural effusion
Uss
Thorocentesis
( diagnostic or therapeutic )
Xray
If a pleural effusion is caused by malignancy , what type of fluid would I suspect ?
Exudate , cell rich
What is sarcoidosis ?
Multi system disorder characterized by non- caseating granulomatous inflammation
Name two conditions that have both granulomas but different types of it
Non-casaeting granuloma in sarcoidosis
Casaeting granuloma ( central necrosis) in TB
What organs are involved in sarcoidosis and how?
Lung : dyspnoea , cough , chest pain
Arthritis
Anterior uveitis
Erythema nodosum
General : fever malaise
Sarcoidosis is classified in 4 types / stages , which ones ?
- Bilateral hilar lymphadenopathy
- Ground glass opacities + hilar lymphadenopathy
- Ground glass opacities but not hilar l.
- Lung fibrosis
How to confirm the suspected diagnosis of sarcoidosis ?
Lung biopsy
Non casaeting granuloma
What is interstitial lung disease and what’s the pathophysiology?
Fibrosis and remodelling of lung interstitium with chronic inflammation type 2 epithelial cells and type 2 pneumocyte hyperplasia
What’s the most common cause of interstitial lung disease ?
Idiopathic pulmonary fibrosis
What clinical features can be seen in interstitial lung disease ?
Dyspnoea on excretion
Dry paroxysmal cough
Bilateral crackles
Name 3 common CT or X-ray findings in interestitial lung disease ?
Honey combing
Bronchiectasis
Thickened interlobular septa
Which systemic disorders can cause interstitial lung disease ?
SLE RA Systemic sclerosis Sarcoidosis UC Autoimmune thyroid
