Pulmonary Flashcards
1
Q
what is a pleural effusion
A
an abnormal collection of fluid in the pleural space
2
Q
what are the symptoms of a pleural effusion?
A
- asymptomatic
- increasing breathlessness
- pleuritic chest pain
- dull ache
- dry cough
- weight loss
- fever
- malaise
- night sweats
3
Q
what are the signs of a pleural effusion?
A
- chest on effected side: decreased expansion, stony dullness to percussion, decreased breath sounds and absent vocal resonance
- clubbing
- tar staining on fingers
- cervical lymphadenopathy
- raised JVP
- trachea deviates away from large effusion
- peripheral oedema
- tumour growth through chest wall (sometimes)
4
Q
What is the definition of transudate causes of pleural effusion?
A
When the pleural fluid protein is less than 30g/l
5
Q
What is the definition of exudate causes of pleural effusion?
A
When the pleural fluid protein is more than 30g/l
6
Q
What are the transudate causes of a pleural effusion?
A
- Left ventricular failure
- Liver cirrhosis
- Hypoalbuminaemia
- Peritoneal dialysis
7
Q
What are the exudate causes of a pleural effusion?
A
- Malignancy
- Parapneumonic
8
Q
What investigations would you do for a transudate pleural effusion?
A
they usually don’t require any investigation
9
Q
What investigations would you do for an exudate pleural effusion
A
- Chest radiograph
- Contrast enhanced CT of thorax
- Pleural aspirations
- Biopsy
- Thoracoscopy
10
Q
What is the management of a pleural effusion
A
- Treatment directed at the cause
- Palliative management (repeated pleura aspirations)
- Pleurodesis
- Surgical procedures (surgical pleurodesis or talc insufflation)
11
Q
What is a pneumothorax?
A
The presence of air within the pleural cavity
12
Q
What are the causes of a pneumothorax?
A
- Primary spontaneous (no clinically apparent disease and is mostly in tall, thin young men)
- Secondary spontaneous (pre-existing lung disease and can happen with pretty much all major lung diseases)
- Non-iatrogenic traumatic (blunt or penetrating chest injury)
- Iatrogenic traumatic (due to Dr. e.g. lung biopsy)
- Tension
13
Q
What are the symptoms of a pneumothorax?
A
- Asymptomatic
- Acute breathlessness, worsening breathlessness
- Pleuritic chest pain
- extreme dyspneoa
14
Q
What are the general signs of a pneumothorax?
A
- No signs if small
- Surgical emphysema
15
Q
What are the signs of a non-tension pneumothorax?
A
- Trachea deviated to the affected side
- Decreased expansion
- Hyper-resonant
- Absent or decreased breathsounds
16
Q
What are the signs of a tension pneumothorax?
A
- Trachea deviates away from affected side
- Haemodynamic compromise
- Increased JVP
17
Q
What is the management of a tension pneumothorax?
A
- Cannula, 2nd intercostal space, midclavicular line
- Then insert chest drain
18
Q
What is the management of a small primary pneumothorax with no breathlessness?
A
- observe overnight, repeat CXR, if no change the hole has sealed
- Discharge, advice no vigorous activity and to return if they are breathless
19
Q
What is the treatment for a breathless primary pneumothorax?
A
- Aspirate pneumothorax (patient at 45 degrees)
- Aspirate until you feel the tip of venflon just beneath the surface of the chest wall
- Aspirate >3L: persistent air leak
- CXR + observation (24h)
- If unsuccessful: chest drain
20
Q
What is the treatment for a secondary pneumothorax?
A
- May try to aspirate if small
- Insert an intercostal chest drain: 4th intercostal space, midaxillary line, small bore 10-14F
21
Q
What is mesothelioma?
A
Pleural malignancy
22
Q
Where else can mesothelioma occur?
A
In the peritoneum
23
Q
What is the main cause of mesothelioma?
A
Asbestos
24
Q
What is the clinical presentation of mesothelioma?
A
- Breathlessness
- Chest wall pain
25
What will you see if you view a mesothelioma radiologically?
- Usually unilateral
| - Diffuse or localised plural thickening
26
What is the management of mesothelioma?
It is essentially palliative care as the life expectancy is 18 months. If a patient dies of mesothelioma you need to remember to refer them
27
What is Otis media?
A middle ear infection
28
What is a complication of Otis media?
Spontaneous rupture of the drum
29
What are the causes of Otis media?
- A primary viral infection
| - Secondary infection with pneumococcus
30
How do you treat Otis media?
- Analgesia usually works
| - Antibiotic treatments don't usually work
31
What is the primary symptom of Otis media?
Pain
32
What are the causes of tonsillitis/pharyngitis?
viral or bacterial
33
What is the test for tonsillitis/pharyngitis?
throat swab
34
What is the treatment for tonsillitis/pharyngitis?
either nothing or 10 days penicillin. Don't give amoxicillin
35
What are the main symptoms for croup?
Corryza, stridor, hoarse voice, "barking cough"
36
What is the treatment of croup?
Oral dexamethasone
37
What is the other name for Epiglottitis?
H. Influenae type B
38
What are the symptoms of epiglottitis?
Stridor and drooling
39
What is the treatment of Epiglottitis?
Incubation and antibiotics
40
What is tracheitis?
croup that does not get better
41
What are the symptoms of tracheitis?
fever, sick
42
What causes tracheitis?
staph. or strep.
43
How do you treat tracheitis?
Augmentin
44
What is Bronchitis?
An endobacterial infection
45
What are the symptoms of Bronchitis?
- Loose rattly cough with URTI
- Post-tissue vomit: "glut"
- chest free of wheeze/ creps
- child is very well, parents very worried
46
What is the natural history of bronchitis?
- Following a UTI
- Last 4 weeks
- 80-80% respond
- First winter is bad but it gets better over the years
- Pneumococcus/ H. flu
47
What are the criteria for persistent bacterial bronchitis?
- wet cough
- more than one month
- goes with antibiotics
48
What is the treatment for bronchitis?
Do not treat this!!!
49
What is Bronchiolitis?
LRTI of infants
50
What causes Bronchiolitis?
RSV, paraflu iii, HMPV
51
What are the symptoms of Bronchiolitis?
- Nasal stuffiness
- tachypneoa
- poor feeding
- crackles +/- wheeze
52
What investigations of Bronchiolitis are done?
- NPA (cohorting)
| - Oxygen saturation (severity)
53
What is the management of Bronchiolitis?
- Maximum observation
| - Minimum intervention
54
What are the symptoms of pertussis?
- Coughing fits
| - Vomiting and colour change
55
What are the symptoms of pneumonia?
- malaise
- Fever
- Pleuritic chest pain
- Cough
- Pleuritic sputum
- Dspnoea
- Head ache
- Rusty sputum
56
What are the signs of pneumonia?
- Pyrexia
- Trachpnoea
- Central cynosis
- Dullness of percussion
- Bronchial breath sounds
- Inspiratory crepitations
- Increased vocal resonance
57
What are the investigations of pneumonia?
-Serum biochemistry and full blood count
-CXR
-Blood cultures
-Throat swab
-Urinary
Sputum microscopy and culture
58
How is the severity on pneumonia scored?
- C: confusion
- U: Blood urea> 7
- R: Respiratory rate> 30
- B: diastolic blood pressure <60
- 65: 65 and over
59
What does it mean if the severity score of pneumonia is 0?
Low risk and it can be treated in the community
60
What does it mean if the severity score of pneumonia is 1-2?
Hospital treatment is usually required
61
What does it mean if the severity score of pneumonia is 3-5?
High risk of death and need for ITU
62
What treatment is given to people with pneumonia with a severity score of 0-1?
Amoxicillin or Clarythromycin/doxycycline
63
What treatment should be given to people with pneumonia with a severity score of 2?
Amoxicillin and Clarythromycin or levofloaxin
64
What treatment should be given to people with pneumonia with a severity score of 3-5?
Co-amoxiclav and Clarythromycin or levofloaxin
65
What other treatments (other than antibiotics) should be given to pneumonia patients?
- Oxygen
- IV fluids (if they are hypertensive or shocked)
- CPAP (Continuous positive airway pressure)
- Intubation and ventilation
66
What are the complications of pneumonia?
- Septicaemia
- Acute kidney injury
- Empyaema
- Lung abscess
- ARDS (acute respiratory distress syndrome)
67
What are the bacterial causes of pneumonia?
- Pneumococcus
- Mycoplasma
- Chlamydia
- Streptococcus pneumonae
- Haemophilus influenzae
- Staphylococcus aureus
68
What are the viral causes of pneumonia?
- RSV (respiratory syncytial virus)
| - Influenza type A or B
69
What is an Empyema?
Infection of the plural space which follows pneumonia but not exclusivly
70
What are the bacterial causes of an Empyema?
- Streptococcus
- Staph. Aureus
- Anaerobes
71
What are the symptoms of an Empyema?
- chest pain (prominent)
| - absence of cough
72
What are the signs of an Empyema?
A high swinging fever
73
What investigations are done for Empyema?
- CT of thorax
| - Plural ultrasound
74
How is Empyema diagnosed?
A diagnostic plural aspiration with a pH<7.2
75
What is the treatment of an Empyema?
- Chest drain
- intravenous antibiotics
- Intrapleural t-PA/DNase (breaks down adhesions)
- Surgery (if no improvement)
76
What are the bacterial causes of a lung abscess?
- Staph. aureus
- Pseudomonas
- anaerobes
77
What are the symptoms of a lung abscess?
- non-specific
- Lethargy
- Weight loss
- High swinging fever
78
What are the investigations done for a lung abscess?
- CT of thorax
| - Sputum culture
79
What is the treatment for a lung abscess?
- prolonged antibiotics
| - Drainage via the bronchial tree
80
What are the atopic causes of asthma?
- Extrinsic asthma (response to allergens)
- most common
- Inflammation mediated by systemic IgE production
81
What are the non-atopic causes of asthma?
- Intrinsic asthma
- not common
- mediated by local IgE production
82
What are the symptoms of asthma?
- Wheezing
- Breathlessness
- chest tightness
- dry irritating cough
- sputum (occasionally)
83
What are the signs of asthma?
- Breathlessness on exertion
- hyper expanded chest
- Polyphonic wheeze
84
What investigations are done for asthma?
- FEV1/FVC (obstructed if <70%)
- FEV1 (obstructed if <80% of predicted)
- Lung volumes (RV/TLC >30%)
- CO gas transfer (should be fine)
- response to bronchodilator (if obstructed)
- Response to oral corticosteroids
- Peak flow meter + chart, twice daily, 2 weeks (variability >20%)
85
WHat specialist investigations are done for asthma?
- methacholine/ histamine responsiveness
- Exhaled NO
- CXR
- Skin prick test (atopic status)
- total and specific IgE (atopic status)
- full blood count (atopy)
86
What non-pharmacological intervention is taken for an acute asthma attack?
- ITU/HDU
- Ventilation
- ECCO2R
- Chest drain if pneumothorax
87
What Non-pharmacological action is taken for chronic asthma?
- Asthma action plan
- Weight loss if a high BMI
- Vaccines- flu and pneumonia
- Allergen avoidance (including occupational asthma)
- Physiotherapy
- Smoking cessation
- Bronchial thermoplasty
88
What bronchodilators are given to asthma patients and are they for acute, chronic or both?
- Beta 2 agonists (both)
- Anti-muscurinics (both)
- Theophyllines (both)
- Magnesium (acute)
- Oxygen (acute)
89
What anti-inflammatory drugs are given to asthma patients and are they for acute, chronic or both?
- Steroids (both)
- Leukotriene RAs (chronic)
- Monoclonal ABs (chronic)
90
What are the drugs to avoid in asthma treatment?
- Beta blockers
- NSAIDs/ Aspirin
- sedatives/ strong opiates
91
What are the advantages of ihalers in asthma treatment?
- Small dose of drug
- Delivered directly to target organ
- Fast acting
- Minimal systemic exposure
- Systemic adverse effects are less frequent and less severe
- Inhaled drug therapy is painless and relatively comfortable
92
What are all the different inhalers?
- Metered dose inhaler
- pMDI with spacer
- Dry powder inhalers
93
What are the advantages of the pMDI with a spacer?
- Low pharyngeal deposition of aerosol
- Reduced speed of the aerosol
- Decreased bad taste associated with oral deposition
- Reduced risk of oral candiditiasis and dysphonia with steroids
- Reduced "clod freon" effect in some
94
What are the aims of asthma treatment?
- No daytime symptoms
- no night time awakening due to asthma
- no need for rescue medication
- No asthma attacks
- No exacerbation
- No limitations on activity including exercise
- Normal lung function
- Minimal side effects from medication
95
What are the drugs for short acting B2-agonists (SABA) and where are they used?
- Salbutamol (MDI + DPI)
| - Terbutaline (DPI)
96
What are the side effects of SABA?
- tremor
- cramp
- Headache
- Flushing
- Palpitations
- Angina
97
When does one start Inhaled corticosteroids (ICS)?
- Taking SABA 3 times a week or more
- Waking one night a week or more
- Requiring oral steroids for exacerbation in the past 2 years
- Sub-normal exercise tolerance or PEFhaled B2 agonists 3 times or more
98
What are the side effects of inhaled long term steroids?
- Dysphonia
| - Oralpharyngeal candidacies
99
What are the side effects of oral long term steroids?
- Red cheeks
- Moon face
- Fat pads buffalo hump
- Bruisability ecchymoses
- Thin skin
- High B.P.
- Red striations
- Pendulous abdomen
- Thin arms and legs
- Poor wound healing
- Osteoprosis compressed (codfish) vertebrae
100
Where is LTRA (leukotriene receptor agonists) more effective?
In those with a long term history of allergy
101
What is theophtlline?
A non-specific enzyme inhibitor and adensosine receptor agonist. It is a week bronchodilator
102
What sre the side effects of Theophylline?
- Anorexia
- Headache
- Nausea
- Malaise
- vomiting
- Nervousness
- Abdominal discomfort
- Insomnia
- Tachycardia
- Trachyarrythmia
- Convulsions
103
What are the disadvantages of Theophylline?
- Narrow therapeutic window
| - Unpredictable metabolism- interactions with many drugs
104
Give an example of an Inhaled long-acting Anti-muscurinic (LAMA)
Tiotropium
105
What does LAMA do?
Antagonises M3 muscurinic Acytylcholine receptor in bronchial smooth muscle (some limited level of benifit in asthma when added to ICS/LABA)
106
What are the side effects of LAMA?
- Dry mouth
- GI upset
- Headaches
- Can rarely precipitate angle-closure glaucoma (ophthalmological emergency)
107
Name the steroid sparing drugs
- Omalizumba (Anti-IgE)
- Mepolizumba
- Immune suppressive drugs:Methotrexate, ciclosporin and oral gold
108
What does Mepolizumba do?
Monoclonal antibody against interleukin-5
109
What is moderate asthma?
- Increasing symptoms
- PEF> 50-75% best or predicted
- No features of acute severe asthma
110
What is acute severe asthma?
- PEF 33-50% best or predicted
- Resp. rate >24/min
- Heart rate>109/min
- Inability to complete sentences
111
What is the clinical signs of life threatening asthma?
- Altered conscious level
- Exhaustion
- Arrhythmia
- Hypotension
- Cynosis
- Silent chest
- Poor resp. effort
112
What are the measurements of life threatening asthma?
- PEF< 33% best or predicted
- SpO2<92%
- PaO2<8kPa
- "normal" PaCO2 (4.6-6.0kPa)
113
What is near-fatal asthma?
Raised PcCO2 and/or requiring mechanical ventilation with raised inflation pressures
114
What do you do in mild/ moderate asthma attack?
- Oral predisolone (0.5mg/kg/day) for 7 days
- SABA (relievers)- more frequently up to 2 hourly
- In some cases ICS/LABA dose as well
- Assess within 24 hours
- Advise immediate medical help if deteriorating
115
What do you do in a sever asthma attack?
- Addmission to hospital
- Oral/IV steroids
- Nebulised bronchodilators- Salbutimol (SABA)/ipratropium (SAMA)
- Oxygen (target sat. 94-98%), consider ABG
- Consider IV MgSO4 if no response
- Antibiotics if there is pneumonia/ bacterial infection
- CXR- pneumothorax + asthma+ bad. needs chest drain if unwell
- Involve senior medical staff including ITU if life threatening (may need anaethaesia, intubation and ventilation and in extreme cases ECCO2R may be life saving)
116
How do you measure the control of asthma in children?
- Short acting beta agonist/week
- Absence from school
- Nocturnal symptoms/ week
- Exertional symptoms/week
117
What are the classes of medication used in the treatment of children's asthma?
- Short acting beta agonist (blue)
- Inhaled corticosteroids (brown)
- Long acting beta agonists
- Theophylline
- Oral steroids
118
What is step zero in the treatment if children's asthma?
- Short acting beta agonists as required
- Inhaled (not oral)
- Spacer/ MDI or dry powder inhaler
119
When does one start step one in the treatment of children's asthma?
- If using SABA inhaler more than 3 times a week
| - Symptomatic three times a week or more, or waking at least one night a week
120
What is step one in the treatment of asthma in children?
A very low dose of inhaled corticosteroids (or LTRA in under 5s)
121
What is step two in the treatment of asthma in children?
Add in either:
- LABA
- LTRA
- Increase ICS dose
122
What are the causes of COPD?
- Smoking
- Chronic asthma
- Passive smoking
- Maternal smoking
- air pollution
- occupation
- delta1- antitrypsin deficiency
123
What are the symptoms of COPD?
- Breathlessness (gradual onset)
- Cough or sputum
- Wheeze
- weight loss
- peripheral oedema
124
What are the signs of COPD?
- Breathlessness walking into clinic
- Pursed lip breathing
- accessory muscles
- Cyanosis
- CO2 flap
- Tremor (beta agonist)
- Bruising
- Cushingoid
- Hyperexpanded chest
- Laryngeal descent
- paradoxical movement of ribs and abdomen
- Breathless sounds (no crackles)
- prolonged expiration with wheeze
- Palpable liver
- Cor pulmonale
- Cardiac dullness to percussion
125
What investigations are done for COPD?
- Sperometry
- Full pulmonary function test (COPD has full gas transfer)
- Chest radiograph
- Blood gasses
- Full blood count
- ECG
- Sputum
126
What is COPD management?
- smoking cessation
- Inhalers
- Vaccines
- Pulmonary rehabilitation
- Management of complications
- SABA
- SAMA
- LAMA
- LABA
- High dose inhaler corticosteroids
- Long term oxygen
127
What is sleep apnoea?
Recurrent episodes of upper airway obstruction leading to apnoea (cessation of breathing for at least 10 seconds) during
128
What is hypopneas?
An almost obstructed airway
129
What are the effects of apnoea?
- Unrefreshed in sleep
- Sleepy during the day
- Poor concentration
130
What are the causes of sleep apnoea?
- Muscle relaxation
- Narrow pharynx
- Obesity
131
What investigations are done for sleep apnoea?
- Epworth questionnaire
- Pulse oximetry
- Limited sleep studies (embletta)
- Full polysomnography
132
What simple lifestyle factors could be changes to treat sleep apnoea?
- Loose weight
- Avoidance of alcohol
- Diagnose and treat endocrine disorders
133
Other than change in life style factors what is the treatment of sleep apnoea?
- CPAP (continuous positive airway pressure)
| - Mandibular airway splint
134
When does narcolepsy often present?
teenage years
135
What are the clinical features of narcolepsy?
- Excessive daytime sleepiness
- Cataplexy (collapse falling asleep)
- Hypnagogic hallucinations
- sleep paralysis
136
What is the treatment of narcolepsy?
- Modafinil
| - Anti-depressant (for cataplexy)
137
What is chronic ventilatory failure?
- Elevated pCO2
- normal pH
- People who have sever sleep apnoea might have this too
138
What are the symptoms of chronic ventilatory failure?
- Breathlessness
- Orthopnoea (breathlessness lying flat due to a weakness of the diaphragm
- Ankle swelling
- Morning head ache
- Recurrent chest infections
- Disturbed sleep
139
Why do people with chronic ventilatory failure have morning head aches?
The rise in CO2 causes vasodilation which causes a headache
140
What investigations are done for chronic ventilatory failure?
- Lung function
- Lying and standing VC
- Mouth pressures/SNIP
- Assessment of hypoventilation
- Fluoroscopic screening of the diaphragm
141
What is the treatment for chronic ventilatory failure?
- Non-invasive ventilation
- O2 therapy
- (t-IPPV) tracheostomy ventilation
142
What causes TB and what is significant about it?
Mycobacteria: it has a very thick wall and so it is resistant to neutrophils and macrophages
143
What are the ways of transmitting TB?
- Source (Coughing, sneezing)
- Large droplets are always cleared from the airway it is the small ones that can get into the alveoli
- Outdoors mycobacteria is eliminated by the UV and infinite dilution and so can only get TB indoors
144
Describe the immunology of TB
- Macrophages are activated by Th1 cells, that travel from the lymph node, releasing IFN-gama CD40
- Macrophages, epithelioid cells and langhan's giant cells accumulate to form a granuloma.
- There is central ceseating necrosis that may calcify later
145
What are the advantages and disadvantages of Th1 cell mediated responce
- Advantage: Eliminates/ reduces the number of invading mycobacteria
- Disadvantage: Tissue destruction is a consequence of the activation of macrophages
146
How does one become more susceptible to TB?
- Getting older
| - Malnutrition
147
What is a primary TB infection?
- No preceding exposure or immunity
- Usually focuses on the alveolus
- spreads via the lymphatic system to all the organs of the body
- Usually no symptoms (but can be fever, malaise, erythema nododum, rarely chest signs
148
What happen in a TB primary infection in the majority of people?
- Initial lesion and local lymph node (primary complex)
| - Heals with and without cells
149
What happens to a small number of people who get a primary TB infection?
- Primary focus continues to enlarge (cavitation)
- Enlarged hylar lymph nodes compresses bronchi, lobar collapse
- Enlarged lymph node discharges into bronchus= TB bronchopneumonia
- Poor prognosis
150
What happens to a small number of people 6-12 months after a primary TB infection?
- Miliary TB: widespread granuloma
- Meningeal TB: sever, CSF high
- TB plural effusion
151
What is a post primary TB infection?
- Reactivation from a latent period: disimminated by the blood stream around the body
- Re-infection from outside source
- May occur at any age
- Can affect any organ in the body
152
What are the symptoms of The post primary disease TB?
- May be no symptoms for months (slow)
- Progressive
- Cough, sputum, haemoptysis, pleuritic pain or breathlessness, systemically unwell, malaise, fever, weight loss, night sweats
153
What are the signs of Post primary disease TB?
- May be none at all
- May be crackles, bronchial breathing (if more advanced)
- Finger clubbing (rare unless chronic)
154
What are the essential investigations of post primary disease TB?
- Sputum smear: ZN stain
- Sputum culture (can take 8 weeks)
- Sputum PCR (good as smear)
- Chest radiograph: patchy shadowing, often apices or apex of the lower lobe, often bilateral, cavitation (if advanced), may calcify (if chronic or healed)
155
What further investigations can you do for post primary disease TB?
- CT scan of the thorax
- Bronchoscopy
- Biopsy
- Plural aspirations
- Fluid cytology
- Fluid for AAFB and culture
- Interferon gamma release assay (IGRA) (this is a negative test)
156
What is treatment of TB for the first 2 months?
- Rifampicin
- Isoniazid
- Ethambitol
- pyrazinamide
157
What is the treatment for TB in the last 4 months of the 6 month treatment plan?
- Rifampicin
| - Isoniazid
158
What are the side effects of Rifampicin?
- Orange urine or tears
- Induces kiver enzymes
- hepatitis
- Increases the metabolism of the oral contraceptive pill, prednisolone and anticonvulsives
159
What are the side effects of Isoniazid
- Hepatitis
| - Peripheral neuropathy
160
What are the side effects of Ethambitol?
-Optic neuropathy
161
What are the side effects of pyrazinamide?
gout
162
After how long does it take TB to be rendered non-infectious?
2 weeks
163
What must you do if you get a case of TB?
- Directly observe therapy
- Notify all cases of TB
- HIV tests
164
Describe TB contact training
- Identify source
- Identify transmission
- Likelihood of infection depends on: duration of contact and intensity of infection
165
What is the most common mutation of the cystic fibrosis gene?
Phe508del
166
What are the main different mutations of the cystic fibrosis gene and what do they do?
- G542X (class 1): makes a truncated mRNA which results in no synthesis of the CFTR
- Phe508del (class 2): no maturation of CFTR
- G551D (class 3): blocked regulation
- R347P (class 4): Decreased conductance
- 3849+10kb C->T (class 5): decreased abundace
167
What is the function of CFTR?
- Activation transport for chloride
- Regulates liquid volume of epithelial surface
- Reduced chloride efflux
- Increased sodium influx
- Cilia colapse
- Excessive inflammation
168
What are the clinical features of CF in antenatal?
- CVS (common)
- Echogenic bowel (common)
- Perforated meconium ileus (less common)
169
What are the clinical features of CF in neonatals?
- Mec ileus (common)
- Gut atresia (less common)
- Obstructive jaundice (less common)
- Vitamin deficiencies (less common)
170
What are the symptoms of CF in infants and young children?
- Recurrent chest infections (common)
- Failure to thrive (common)
- Rectal prolapse (less common)
- Pseud-bartter's syndrome (less common)
- Anaemia (less common)
- Oedema (less common)
- Hypoproteinaemia (less common)
171
What are the symptoms of CF in older children and aldults?
- Recurrent chest infections (common)
- Nalsal polyps and sinusitis (common)
- Male infertility (common)
- Acute pancreatitis (less common)
- Liver disease (less common)
- Pseudo-Bartter's atypical mycobacteria
172
What is the screening for CF?
- New born blood spot day 5
- Initial screening: immuno-reactive trypsinogen
- If positive referred to sweat tests
- Both stages miss a portion of cases
173
What is included in the management of CF?
- Specialist multi-organ disciplinary team
- Shared care with local clinic
- Primary care: surveillance and treatment of infection
174
What are the two cardinal features of CF?
- Pancreatic insufficiency
| - Recurrent Bronchopulmonary infection
175
What does pancreatic insufficiency result in?
- Abnormal stool (pale or orange, very offensive, greasy or oily)
- Failure to thrive: many thrive quite well on breast milk, may have deficiencies in fat soluble vitamins
176
What is the treatment for pancreatic inefficiencies?
- Enteric coated enzyme pellets
- High energy diet (not low fat)
- Fat-soluble vitamin and mineral supplements
- H2 antagonists or proton pump inhibitors
177
What does recurrent Bronchopulmonary infections result in?
- Pneumonitis
- Bronchiectasis
- Scarring
- Abscesses
- Common organisms: staphylococcus aureus and haemophilus influenza (early years), Pseudomonas maltophilia (later years)
- Less common organisms
178
What is the management of recurrent Bronchopulmonary infections?
- Try to prevent cross infection
- Airway clearance
- Mucolytics
- Prophylactic antibiotics
- Annual influenza vaccines
- Try to erradicate infection
179
What are the other manifestations (general)?
- Upper airway polyps and sinusitis
- Diabetes
- Bones: osteopenia, arthropathy
- Heat exhaustion
- Bilateral absence of vas deferens
- Vaginal candidiasis, stress incontanance
180
What are the other manifestations (GI)
- Dysmotility: Meconium ileus, Gastro-oesophogeal reflux, Distal intestinal obstruction, constipation/ rectal prolapse
- Co-existance disease
- Crohn's and coeliac
181
What is the interstitium of the lungs?
The connective tissue space around the airways and vessels and the space between the basement membranes of the alveolar walls
182
What is restrictive lung disease?
- Reduced lung compliance (stiff lungs)
- Low FEV1 and low FVC but FEV1/FVC is normal ratio
- Reduced gas transfer (diffusion abnormality)
- Local ventilation/ perfusion imbalance
183
What is the presentation of diffuse lung disease?
- Discovery of abnormal CXR
- Dyspnoea (initially on exertion but eventually during rest)
- Type 1 respiratory failure
- Heart failure (because it is hypoxic)
184
What are the types of Diffuse lung disease?
- Usual interstitial pneumonitis UIP
- Granulomatous responses
- Other patterns
- Fibrous or end-stage honeycomb pattern
185
What are the other names for diffuse alveolar damage (DAD)?
- Adult respiratory distress syndrome (ARDS)
| - Shocked lung
186
What is DAD associated with?
- Major trauma
- Chemical injury/ toxic inhalation
- Circulatory shock
- Drugs
- Infection
- Auto(immune) disease
- Radiation
- Idiopathic
187
What are the histological features of DADS
-Protein rich oedema
-Fibrin
Hylaine membranes
-Denuded basement membranes
-Epithelial proliferation
-Fibroblast proliferation
-Scaring (interstitium and airspaces)
188
What is sarcoidosis?
- A multi-system granulomatous disorder of unknown aetiology
- Commonly effects young adults F>M
- Most common sites are the lungs and the lymph nodes
189
What are some of the histological features of sarcoidosis?
- Epitheliod and giant cell granuloma
- Necrosis/ caseation very unusual
- Little lymphoid infiltrate
- Variable associated fibrosis
190
What is the presentation of sarcoidosis?
1. Young adult
- Acute arthralgia
- Erythema nodosum
- Bilateral hilar lymphhadenopathy
2. Incidental abnormal CXR- no symptoms
3. SOB, cough and abnormal CXR
191
How do you diagnose sarcoidosis?
- Clinical findings
- Imaging findings
- Serum Ca++ and ACE
- Biopsy
192
What treatment is given for sarcoidosis?
Corticosteroids
193
What is hypersensitivity pneumonitis?
- Large group of disease
| - Caused by the inhalation of organic antigens or microorganisms that the host has become sensitised
194
What antigens causes hypersensitivity pneumonitis?
- Thermophilic actinomycetes
- Bird/ animal proteins
- Fungi (aspergillus spp.)
- Chemicals
- Others
195
What is the acute presentation of hypersensitivity pneumonitis?
- Fever
- Dry cough
- Mylagia
- Chills 4-9 hours after Ag exposure
- Crackles
- Tachypnoea
- Wheeze
- Precipitating antibody
196
What is the chronic presentation of hypersensitivity pneumonitis?
- Insidious
- Malaise
- SOB
- Cough
- Low grade illness
- Crackles and some wheeze
197
What is the histopathology of hypersensitivity pneumonitis?
- Immune complex mediated combines type III (lymphatic infiltrate) and type IV (hyp granulomas)
- Soft centriacinar eoitheliod graunlomata
- Interstitial pneumonitis
- Foamy histocytes
- Bronchiolitis oblterans
- Upper zone disease
198
Where might usual interstitial pneumonitis be seen?
- Connective tissue disease
- Drug reaction
- Post drug infection
- Industrial exposure (asbestos)
- Others
- Most are cryptogenic or idiopathic
199
What is the histopathology of Usual interstitial pneumonitis?
- Patchy interstitial chronic inflamation
- Type II pneumocyte hyperplasia
- Smooth muscle and vascular peoliferation
- Evidence of old and recent injury
- Proliferating fibroblastic foci
200
How is idiopathic pulmonary fibrosis clinically shown?
- Dyspnoea
- Cough
- Basal crackles
- Cyanosis
- Clubbing
201
Which gender is effected by idiopathic interstitial fibrosis more?
Males
202
What is the likely outcome of idiopathic pulmonary fibrosis?
- most are dead within 5 years
- Some respond to fulminant some steroids
- Increased risk of developing lung cancer
203
What diffuses faster CO2 or O2
CO2 diffuses 20X faster than O2 due to increased solubility
204
How long does equliberation usually take?
0.25 seconds
205
How long is capillary transit time?
normally 0.75 seconds
206
What is a pulmonary embolism?
- A thrombus forms in the venous system (often deep veins in the legs) and embolises to the pulmonary region
- Massive PE can be fatal but a minor PE can be treated with anticoagulants and has a good prognosis
207
What are the major risk factors of a pulmonary embolism?
- Recent major trauma
- Recent surgery
- Cancer
- Significant cardiopulmonary disease e.g. MI or COPD
- Pregnancy
- Inherited thrombophilia e.g. factor V leiden
208
What are the symptoms of a pulmonary embolism?
1. Isolated small blood clot in the pulmonary artery
-Pleuritic chest pain
-Cough
-Haemoptysis
2.Bi-lateral blood clot to the pulmonary artery
-Isolated acute dyspnoea
3. massive PE
-Syncope
OR
-Cardiac arrest
209
What are the signs of a pulmonary embolism?
1. Isolated small blood clot in the PA
- Pyrexia
- Plural rub
- Stony dullness to percussion at the base
2. Bi-lateral blood clot to the PA
- Tachycardia
- Tachypnoea
- Hypoxia
3. Massive PE
- Tachycardia
- Hypotension
- Tachypnoea
- Hypoxia
210
What investigations are done for Pulmonary embolisms?
- Wells score
- Revised geneva score
- Full blood count, biochemistry and blood gases
- CXR
- ECG
- D-dimer
- CT pulmonary angiogram
- V/Q scan
- Echocardiography
- CT abdomen and mammography
- Thrombophilia testing
211
What is the treatment for a pulmonary embolism?
- Oxygen
- Low molecular weight heperin e.g. delteparin
- Warfarin
- Direct oral anticoagulants e.g. rivaroxaban or apixaban
- Thrombolysis e.g. Alteplase (rt-PA)
- Pulmonary embolectomy
212
What is pulmonary hypertension?
- Elevated blood pressure in the pulmonary arterial tree
- Defined as a mean pulmonary artery pressure of >25mmHg
- Either primary (often effects younger people) or secondary to other conditions
213
What are the causes of pulmonary hypertension?
- Idiopathic (primary hypertension)
- Secondary chronic respiratory disease
- Secondary to chronic left heart disease
- Chronic thromboembolic pH
- Misc.: collagen vascular disease, potal hypertension, congenitl heart disease, HIV infection
214
What are the symptoms of Pulmonary hypertension?
- Mild and subtle, can be mistaken for asthma
- Exertion dyspnoea
- Chest tightness
- Exertional presyncope or syncope
215
What are the signs of Pulmonary hypertension?
- Elevated JVP
- Right ventricular heave
- Loud pulmonary second heart sound
- Heptomegaly
- Ankle oedema
216
What investigations are done for pulmonary hypertension?
- ECG
- Lung function tests
- CXR
- Echocardiography
- V/Q scan
- CTPA
- Right hear catherisation
217
What is the treatment for Pulmonary hypertension?
- Treat underlying condition
- Oxygen
- Anticoagulants
- Diuretics
- CCBs e.g. amlodipine
- Prostacyclin
- Endothelium receptor antagonists e.g. bosentan or ambrisentan
- Phosphodiesterase inhibitors (sildinafil or tadalafil)
- Thrombo-endarectomy (CTEPH)
- Lung or heart transplant
218
What is the aetiology of lung cancer?
- Tobacco
- Asbestos
- Environmental radon
- Other occupational exposure: chromates, hydrocarbons, nickel
- Air pollution and urban environment
- Other radiation
- Pulmonary fibrosis
219
How much is the risk of lung cancer increased due to smoking
increased 22X in males and 12X in females but females are more suseptable
220
What are the two main pathways of carcinogenesis in the lung?
- In the lung periphery: bronchioloaveolar epithelial stem cells transform, Adeno-carcinoma
- In the central lung airways: bronchial epithelial stem cells transform, squamous cell carcinoma
221
Which type of lung cancer can occur in non-smokers?
Adeno-carcinoma
222
What are the mutations that cause adenocarcinogenesis?
- KRAS (smoking induced)
- EGFR
- BRAF
- HER2
- ALK rearrangements
- Lots left and we do not know the key molecular cahnges (most smoking induced)
223
What are the tumours of the lung?
- Benign causes of mass lesion
- Carcinoid tumour
- Tumours of bronchial glands (V. rare)
- Lymphoma
- Sarcoma
- Metastases to the lung are common
224
Name the tumours of bronchial glands
- Adenoid cyctic carcinoma
- Mucoepidermoid carcinoma
- Benign adenomas
225
What are the four main types of carcinoma in the lung?
- Squamous cell
- Adenocarcinoma
- Small cell carcinoma
- Large cell carcinoma
226
What is primary lung cancer?
- Probably grows clinically silent for many years
- Presents late in its natural history
- May have few, if any, signs or symptoms until the disease is very advanced
- May be found incidentally, during investigation for something unrelated
- Generally speaking symptomatic lung cancer is fatal
227
What are the local effects of lung cancer?
- Bronchial obstruction: collapse, endogenous lipoid pneumonia, infection/ abscess, bronchiectasis
- Plural: Inflammatory, malignant
- Direct invasion: chest wall
- Lymph node metastases: mass effect, lymphangitis carcinomatosa
228
What nerves can lung cancer affect and what does this result in?
- Phrenic: diaphragmatic paralysis
- L. recurrent laryngeal: hoarse, bovine cough
- Brachial plexus: pancoast T1 damage
- Cervical sympathetic: Horner's syndrome
229
What are the distant effects of lung cancer?
- Distant metastases: liver, adrenals, bone, brain, skin
- Secondary to local effects: neural, vascular
- Non-metastatic effects
230
What are the non-metastatic para-neoplastic skeletal effects of lung cancer?
- Clubbing
| - HPOA
231
What are the non-metastatic para-neoplastic Endocrine effects of lung cancer?
- ACTH (small cell), siADH (small cell), PTH
- Carcinoid syndrome
- Gynecomastia
232
What are the non-metastatic para-neoplastic neurological effects of lung cancer?
- Polyneoropathy
- Encephalopathy
- Cerebellar degeneration
- Myasthenia (Eaton-Lambert)
233
What are the non-metastatic para-neoplastic Cutaneous effects of lung cancer?
- Acacthosis nigricans
| - Dermatomysitis
234
What are the non-metastatic para-neoplastic Haematologic effects of lung cancer?
- Granulocytosis
- Eosinophilia
- DIC
235
What are the non-metastatic para-neoplastic cardiovascular effects of lung cancer?
Thrombophlebitis migrans
236
What are the non-metastatic para-neoplastic renal effects of lung cancer?
Nephrotic syndrome
237
What are the non-metastatic effects of lung cancer?
- Finger clubbing
| - Hypertrophic pulmonary osteoarthropathy (HPOA)
238
What investigations are done for lung cancer?
- CXR
- Sputum cytology (rarly used)
- Bronchoscopy: bronchial biopsy, Bronchial brushings and washings, endobronchial US-guided aspiration (EBUS)
- Trans-thoracic fine needle aspiration
- Trans-thoracic core biopsy
- Pleural effusion
239
What are the advanced imaging techniques for lung cancer?
- CT scanning
- MRI, PET
- Other imaging
240
What are the predictive factors in lung cancer?
- Adenocarcinoma: EGFR, KRAS, HER2, BRAF mutations, ALK transloactions etc. etc.
- Squamous cell: FGFR1 gene copy number, DDR2 and FGFR2 mutations etc. etc.
241
What is the first test for lung cancer?
Chest radiograph
242
What should you look for in a chest radiograph for lung cancer?
- Cancers like to hide in the hilum and so you should make sure the vascular structures are clear and defined, there is no widening of the mediastinum and that the trachea is central
- Compare the upper and the lower zones
- Look between ribs for lung detail
- Look behind heart
- Beware lobar collapse that fails to resolve in 2-3 days in smokers
- Beware lesions behind the heart and the hila
- Compare with previos films
243
What are the review areas of a CXR you should look at for lung cancer?
- Hila
- lung apices
- Behind the heart
- Behind the diaphragm
244
What is the second step you should take for staging lung cancer?
CT
245
What should you evaluate in a CT when concdering lung cancer?
- Size
- Shape
- Atelectasis (compete or partial collapse of the lung)
- Border
- density
- Solid or non-solid
- Dynamic contrast enhancements >25 HU
- growth
246
What nodules and masses should you look for in lung cancer?
- Pulmonary nodule: pulmonary opacity in the lung up to 3cm with no mediastinal adenopathy or atelectasis
- Pulmonary mass: pulmonary opacity in the lung more than 3cm with no mediastinal adenopathy or atelectasis
247
What possible things could a ode or a mass in the lungs could be?
- Lung cancer
- Metastases
- Benign lung neoplasm e.g. carcinoid hemartoma
- Infection bacterial, TB or fungal
- Vascular haematoma, AVM
248
What is the international system for staging lung cancer?
TNM
- T: how big it is and how far it has spread/ size and position of the tumour
- N: whether cancer cells has spread into the lymph nodes
- M: Whether the tumour has spread anywhere in the body
249
What techniques are used to determine T,N and M in lung cancer?
- T: CT, PET-CT, Bronchoscopy
- N: PET-CT, mediastinoscopy (invasive technique sampling lymph nodes), CT, EBUS/EUS (sample lymph nodes)
- M: PET-CT, CT, bone scan
250
What allows you to see a tumour better in a PET scan?
Labelled glucose analogue 18F-FDG which the tumour recognises as glucose and takes in allowing you to see the tumour easier
251
What are the disadvantages of a PET scan
- It's expensive
| - There are both false positives and false negatives
252
What are the advantages o a PET scan?
- Preforms a whole body scan in a single study (excluding cerebral disease)
- Discloses metastases and other pathology not detected bu other means
- Excludes metastases where structural imaging is not available
- Non-invasive
253
What are the 10 clinical features of lung cancer (in order of appearance)?
1. Chronic coughing
2. Coughing up blood
3. Wheeze sound
4. Chest and bone pain
5. Chest infections
6. Difficulty swallowing
7. Raspy, hoarse voice
8. Shortness of breath
9. Unexpected weight loss
10. Nail clubbing
254
What are the metastatic features of lung cancer?
- Bone pain
- Spinal cord compression: Limb weakness, paraethesia (pins and needles), bladder/ bowel dysfunction
- Cerebral metastases: Head ache, vomiting, dizziness, ataxia (the loss of full control of bodily movements), focal weakness
- Thrombosis
255
What are the Paraneoplastic features of lung cancer?
- Hyponatraemia (low sodium levels): SIADH (inappropriate ADH secretions)
- Anaemia
- Hypercalcaemia: Parathyroid related protein, bone metastasis
- Dermatomyositis/ polymyositis: proximal muscle weakness
- Eaton-Lambert syndrome: upper limb weakness
- Cerebellar ataxia
- Sensorimotor neuropathy
256
What are the clinical signs of lung cancer?
- Chest signs
- Clubbing
- Lymphadenopathy
- Horner's syndrome
- Pancoast tumour
- Superior vena cava obstruction
- Heptomegaly
- Skin nodules (metastases)
- Commonly may not have any signs
257
What are the initial investigations you do for lung cancer?
- CXR
- FBC
- Renal, liver functions and calcium
- Clotting screen
- Spirometery
258
What is the treatment for lung cancer?
- Surgery: wedge resection, lobectomy, pneumonectomy
- Radiotherapy: Radical, palliative, stereotactic
- Chemotherapy
- Best supportive care
- Co-coordination: lung cancer specialist nurse
259
What is the palliative management of lung cancer?
- Symptom control: may include chemotherapy or radiotherapy, opiates, bisphosphonates, Benzodiasepines, treatment of hypercalcaemia, dehydration, hyponatraemia
- Quality of life
- community support
- Decisions and planning, resuscitation status, end of life care
- Multidisciplinary team including lung cancer nurse and hospice
260
What is the eastern cooperative group (COCG) performance status measurement?
```
0= asymptomatic; well
1= symptomatic; able to do light work
2= has to rest but for <50% of the day
3= has to rest for >50% of the day
4= bedbound
```
261
When is adjuvant therapy done?
- Postoperative
- Non small-cell lung cancer
- To increase the chance of cure
262
When is adjuvant RT detrimental?
in stage I and II
263
When is there some benefit possible for adjuvant RT?
if mediastinal nodes or involved margines
264
What drugs are given in stage IB and II that improve the 5 year survival by 15%
cicplatin and vinorelbine
265
What non-surgical treatment has proven beneficial during stage II
preoperative chemotherapy
266
What dose is given for stage III NSCLC in radical radiotherapy?
55Gy +
267
What is essential to do when undertaking radical radiotherapy?
pulmonary function tasts
268
What is the cure for stage IV NSCLC?
it's incurable
269
What is better in stage IV NSCLC, RT or chemo?
- RT has symptom benefit
| - Chemo has equal system benefit and survival advantages
270
What should be given if there is painful bone metastases in NSCLC?
RT single fraction
271
What should be given if there is brain metastases in NSCLC?
- Resection
- RT
- steroids
- or erlotinib
272
What treatment is is given for bone pain from metastases?
- Orthopaedic surgeons
- Neurosurgeons (cord compression)
- Palliative RT
273
What are the target drugs for adenocarcinoma with EGFR mutation?
- erlotinib
- gefitinib
- afatinib
274
What are the target drugs for adenocarcinoma with ALK translocation?
- Crizotinib
| - ceritinib
275
What are the target drugs for adenocarcinoma with BRAF mutation?
- Vemurafenib
| - dabrafenib
276
What are the target drugs for adenocarcinoma with ROS alteration?
Crizotinib
277
What does Nivolumad BMS do?
- A mode of action that potentiates the immune system
- blocks the binding of PD-1 to PD-L1 and PD-L2
- Potentiates the activity of T-lymphocytes by preventing them from being activated
278
What are the treatments of small cell lung cancer?
- Chemotherapy treatment of choice
- Combination of drugs e.g. cicplatin + etoposide
- Early (ideally concurrent) thoracic RT better
- Prophylactic cranial radiation
279
What is there no advantages from in small cell lung cancer?
- High dose chemo
- Alternating chemo
- Maintenance chemo
- Chemo "on demand"
- Maintenance interferon, MMPI, targeted therapies
280
What should be given if there is brain metastases in SCLC?
RT and steroids
281
What is looked for when assessing a patients fitness for surgery for lung cancer?
- CVS: angina, heart probs. HBP, DM, PDV, smoking, stroke/ TIA, carotid bruits, previous CABG/ angioplasty, heart murmurs
- Resp: Barrell-chested, COAD, still smoking, asthmatic, recent URTI, on oxygen, exercise capacity, previous thoracotomy or ICD
- Psch: PH of mental illness, sever anxiety, social backround, chronic pain probs.
- Other: pulmonary hypertension, permanent tracheostomy, rheumatoid arthritis, the immobile patient, cirrhosis, h/o radiotherapy to chest
282
How is respiratory function tested when considering a lung cancer patient for surgery?
- Spirometry
- Diffusion studies
- ABG on air/SLV
- Fractionated V/Q scan
283
What is the cardiac assessments when considering a lung cancer patient for surgery?
- ECG
- ECHO
- CT scan
- ETT
- Coronary angiogram
- If in doubt don't operate
284
What are the goals of surgical treatment of lung cancer?
- Current resection
| - Remove the minimum amount of lung tissue
285
What are the reasons for preoperative death in surgery for lung cancer?
- ARDS
- Bronchopneumonia
- Myocardial infarction
- PTE
- Pneumothorax
- Intrathoracic bleeding
286
What are the non-fatal complications of surgery for lung cancer?
- Post thoracotomy wound pain
- Empyema
- BPF
- Wound infection
- AF
- MI
- Post-op respiratory insufficiency
- Gastroparesis/ constipation
287
What are the operative treatments that are available for patients with lung cancer?
- Pneumonectomy
- Lobectomy
- Wedge resection
- Open/ closed thoractomy
288
What is the average volume of oxygen exchanged per minute?
250ml
289
What is the average volume of carbon dioxide exchanged per minute?
200ml
290
Which bronchi is shorter?
Right
291
What are type one pneumocytes?
- simple squamous epithelium
| - Gas exchange
292
What are type 2 pneumocytes?
- Surfactant: Phospholipids and protein
- Reduces surface tension
- Reduces work of breathing
293
Describe the pleura
- Inside: parietal pleura
- Middle: interpleural fluid
- Outside: Visceral pleura
294
Describe Boyle's law
- Increased volume= decreased pressure
| - decreased volume= increased pressure
295
What muscles does inspiration use?
- External intercostal muscles
- Diaphragm
- Sternomastoids
- Scalenes
296
What muscles does expiration use?
- It is a passive possess
- Internal intercostal
- Abdominal muscles
