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PULMONOLOGY Flashcards

1
Q

What are the causes of COPD?

A

Smoking
a-1 antitrypsin deficiency
Dust e.g. cadmium, coal, cotton, cement, grain

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2
Q

What are the symtoms of COPD?

A

Cough (productive)
Wheeze
Dyspnoea

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3
Q

What are the signs of COPD?

A 
Tachypnoea
Accessory Muscles
Hyperinflation
Hyperresonence
Reduced expansion
Reduced breath sounds e.g. over bullae 
Reduced corticosternal distance 
Cyanosis
Cor pulmonale (raised JVP)
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4
Q

What are the complications of COPD?

A 
Acute exacerbations (+/- infection)
Respiratory failure
Polycythaemia abnormal increase in Hb
Pneumothorax due to ruptured bullae
Lung carcinoma
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5
Q

What are the stages of COPD?

A 
FEV1
1 Mild >80%
2 Moderate 50-79%
3 Severe 30-49%
4 Very severe 30%
\+ post bronchodilator FEV1/FVC <0.7

BUT the patient must be experiencing symptoms to diagnose

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6
Q

What are the signs of COPD on CXR?

A

Hyperinflation
Bullae
Flat hemidiaphragm
Hyperlucent lung fields

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7
Q

What are the investigations for COPD?

A
  • Spirometry
  • FBC
  • CXR
  • BMI
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8
Q

How is COPD managed?

A
  1. Stop smokinh
  2. Flu vaccine (annual) and pneumococcal vaccine (one-off)
  3. SABA OR SAMA
  4. FEV1 > 50% LABA or LAMA
    FEV1 <50% LABA + ICS or LAMA
  5. Oral theophylline (reduce if giving macrolide or fluoroquinolone)

Persistant exacerbation/ breathlessness: LABA+ICS_LAMA

Mucolytics for productive cough

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9
Q

What can improve survivial in COPD?

A
  • Stop smoking
  • Lung volume reduction surgery
  • Long term O2 therapy
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10
Q

When should long-term O2 therapy be considered?

A 
FEV1 <30% 
Cyanosis
Polycythaemia
Peripheral oedema
Raised JVP
PO2 <92% on room air
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11
Q

When should long-term O2 therapy be offered?

A

2 blood gasses, 3 weeks apart

pO2 < 7.3kPA or 7.3-.8kPA + 1 of…

  • Secondary polycythemia
  • Nocturna; hypoxaemia
  • Peripheral oedema
  • Pulmonary HTN
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12
Q

What microorganisms cause acute exacerbations of COPD?

A

H. Influenzae
S. Pneumoniae
Maroxella Catarrhalis
30% are viral

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13
Q

How are exacerbations of COPD managed?

A

Nebbed bronchodilator
7-14 days of prednisolone
Abx ONLY if sputum is purulent OR clinical signs of pneumonia

NIV when pH 7.25-35

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14
Q

What are ‘pink puffers’?

A

Primarily emphysema

Destruction in small airways leads to destruction of capillary beds so reduced O2 of Hb causing hyperventilation ‘puffers’ but with normal ABGs-less hypoxic so ‘pink’

TYPE 1 resp failure

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15
Q

What are ‘blue bloaters’?

A

Primarily chronic bronchitis

Redueced alveolar ventialtion so reduced O2 and reduced CO2

Cyanosed but not breathless (blue)

Chromic alveolar hypoxia leads to pulmonary HTN and R heart failure so oedematous (bloated)

Hypoxic drive maintains respiratory effor

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16
Q

What is Asthma?

A

TYPE I hypersensitivity (IgE) reaction causing CHRONIC INFLAMMATION OF THE AIRWAYS

REVERSIBLE BRONCHOSPASM (causing airway obstruction) due to:

  • Bronchial muscle contraction
  • Mucosal inflammation by mast cells and basophil degranualtion releasing inflammatory mediators
  • Increased mucous production
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17
Q

What are the risk factors for Asthma?

A 
Atopy: eczema, hayfever
Not breast fed
Maternal smoking 
Very clean house
Multiple siblings
Hygiene
Aspirin
Occupational
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18
Q

How does asthma present?

A

Widespread Expiratory Polyphonic Wheeze
Hyperinflated chest-hyperresonnance
Obstruction
Nocturnal cough

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19
Q

What are the investigations for Asthma?

A

PEF
Spirometry
FEV1(reduced)/FVC(normal) <70%

Reversed when given SABA (improvement >12% and increase in volume >200ml

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20
Q

How is Asthma managed?

A 
SABA (Salbutamol)
\+
ICS (Beclamethasone dipropionate or Fluicasone Proprionate) 100mch 2x2
\+
LEUKOTRIENE RECEPTOR ANTAGONIST
(Oral monteleukast) 
\+
LABA (Salmeterol) (review LTRA)
\+
Convert ICS and LABA to MART regimen (combined inhaler) with low maintenance ICS dose
\+ 
Convert ICS to moderate dose 200mcg 2x2
\+
Increase ICS to high dose 
or Trial LAMA or THEOPHYLLINE
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21
Q

How is acute asthma classified?

A

Moderate:

  • Worsening symptoms
  • PEF <75% best/predicted
  • No features of acute severe

Severe: any of

  • PEF 33-50%
  • RR >25
  • HR >110
  • Can’t complete sentances

Life-threatening: any of

  • PEF <33%
  • O2 <92% <8kPa
  • Cyanosis
  • CO2 normal
  • Silent chest
  • Poor respiratory effort and exhaustion
  • Arrhythmias
  • Hypotension
  • Altered consciousnes

Near-fatal:

  • Raised CO2
  • Any need for ventilation assistance (low pH)
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22
Q

How is acute asthma managed?

A

Nebulise 5mg salbutamol through oxygen
Teotropium Bromide
Oral prednsiolone (continue 40-50mg 5 days after) or IV hydrocortisone
Magnesium sulphate IV

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23
Q

What is Pneumonia?

A

Inflammation of the alveoli in a lobar pattern

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24
Q

How is Pneumonia classified?

A

CAP v HAP

Acute v Chronic

Causative organism: bacterial v viral v fungal

Lung pathology:
- Lobar- S. Pneumoniae
Alveoli fill with plasma exudate and neutrophils-consolidation on CXR
- Broncho-patchy consolidation of different lobes
- Interstitial- H. Influenze
Accumulates of infiltrates into the alveolar walls, walls thicken, increased diffusion distance and irritated walls cause dry cough

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25
What are the causative organisms of Pneumonia?
Streptococcus Pneumoniae Staphylococcus Aureus Haemophilus Influenzae Klebisiella Pneumoniae Atypical: Mycoplasma pneumonia Legionella pneumophillia Chlamydia Psittaci Fungal: Pneumocystis jiroveci
26
What are the non-infective causes of Pneumonia?
- Aspiration Pneumonia | - Idiopathic interstitial Pneumonia
27
What is Streptococcal Pneumoniae Pneumonia?
Majority of cases High fever Rapid onset Rusty sputum >60 y/o Associated with herpes virus Vaccine available
28
What is Staphylococcal Pneumoniae Pneumonia?
After recent flu | IVDU
29
What is Haemophilus Influenzae Pneumonia?
COPD | Dry cough
30
What is Klebisiella Pneumoniae Pneumonia?
Alcoholics Diabetics 'Red-current jelly' sputum Upper lobes Aspiration Causes lung abscesses and empyema
31
How are the typical pneumonias treated?
Amoxicillin for 5 days (Macrolide if penicillin allergic: doxycycline, Erythromycin or Clarithromycin) If severe then add a macrolide for 7 days Co-amoxiclav + clarithromycin/doxycycline/ceftriaxone/piptaz
32
What is Mycoplasma Pneumonia?
Atypical-won't respond to penicillins as no peptidoglycan wall Younger patients Dry cough Flu-like symptoms Deranged LFTs Bilateral CXR consolidation Treat with macrolides e.g. Clarithromycin or Erythromycin or Tetracyclines e.g. Doxycycline
33
What are the complications of Mycoplasma Pneumonia?
``` Complications: Cold agglutinins (IgM) cause (+ve test): Autoimmune haemolytic anaemia Thrombocytopenia Erythema multiforme Meningoencephalitis Guilla-Barre Peri/myocarditis Bullous myringitis (painful vesicles on tympanic emembrane-inflamed) Hepatitis Pancreatitis Acute gomerulonephritis ```
34
What is Legionella pneumophillia
legionnaire's Water tanks so air-conditioning ``` Flu-like fever Dry cough Bradycardia Confusion Pleural Effusion ``` Lymphopaenia Hyponatreamia Deranged LFTS Macrolides Erythromycin or Clarithromycin
35
What is Chlamydia Psittacosis Pneumonia?
Parrots, poultry and sheep Human to Human Tetracyclines
36
What is Pneumocystis jiroveci Pneumonia?
HIV (most common opportunistic infection in AIDS) CD4+ <200 ``` Dry cough Dyspnoea Fever Exercise-induced desaturation Absence of chest signs Bronchoalveolar lavage-silver stain shows cysts (sputum often fails to show PCP) CXR: Bilateral interstitial pulmonary infiltrates Ground glass opacity Pneumothorax is a common complication ``` Extrapulmonary (rare) Hepatosplenomegaly Lymphadenopathy Choroid lesions Co-trimoxazole IV pentamidine Steroids if hypoxic
37
What is Aspiration Pneumonia?
Foreign materials (e.g. saliva or food) entering the bronchiole tree Risk factors: - Incompetent swallowing - Neurological diseases e.g. stroke and MS - Intoxication - Poor dental hygiene - Impaired consciousness - Impaired mucociliary clearance - Prolonged hospitalisation/surgical procedures e.g. intubation Chemical: acidic pneumonitis Bacterial pathogens S. Pneumoniae, S. Aureus. H. Influenzae, Pseudomonas aeruginosa
38
What is Idiopathic Interstitial Pneumonia?
Non-infective pneumonia e.g. Cryptogenic organising pneumonia (bronchiolitis due to RA or amiodarone) can cause ground-glass opacity
39
What is Viral Pneumonia?
Damage to cells lining the airways/alveoli, alveoli fill with fluid impairing gas exchange Severe viral pneumonia results in necrosis/haemorrhage into the lung parenchyma and presents like ARDS Ground glass opacity (diffuse or patchy) on CXR
40
What are the risk factors for Lung Cancer?
SMOKING (x10) Asbestos (x5) (Arsenic, Radon, Nickle, Chromate)
41
What are the types of Lung Cancers?
Small Cell 15% Non-Small cell: - Squamous 35% - Adenocarcinoma 30% - Large-cell 10% - Bronchial adenoma
42
How are Lung Cancers investigated?
1. Contrast CT 2. CXR (10% are reported as normal) - Peripheral nodule - Hilar enlargement - Consolidation - Lung collapse - Pleural effusion - Boney secondaries 3. Bronchoscopy to biopsy 4. PET scan for Non-Small Cell to establish eligibility for treatment 5. Cytology - Sputum - Pleural fluid 6. Lung function tests
43
How do Lung Cancers Present?
``` Cough Haemoptysis Dyspnoea Chest pain Slow resolving/recurrent pneumonia Cachexia Anaemia Clubbing Supraclavicular or axillary lymph nodes Hypertrophic Pulmonary Osteoarthropathy (wrist pain) ```
44
What are the paraneoplastic syndromes and complications for Small-Cell Lung Cancer?
- ADH (SIADH) hyponatreamia - ACTH cushing's - Lambert-Eaton syndrome is like myesthenia
45
How is Small-Cell Lung cancer managed?
Nearly always disseminated (only ~20% are suitable for surgery) May respond to radio and chemo-mostly used for palliation (reduce bronchiole obstruction)
46
What are the features, paraneoplastic syndromes and complications of squamous cell lung cancers?
Central, cavitating tumours Finger clubbing PTH-rp -> hypercalcaemia TSH -> hyperthyroid
47
What are the features of Adenocarcinomas?
Typically peripheral | Most common in non-smokers
48
What are the features and paraneoplastic syndromes of Large-cell lung cancers?
Typically peripheral Anaplastic, poor differentiation and poor prognosis Secrete B-HCG Gynaecomastia
49
How are Non-Small Cell Lung Cancers managed?
Excision if: - SVC occluded - FEV <1.5 - Malignant pleural effusion - Vocal cord paralysis Radiotherapy can be curatice Add platinum-based chemo if advanced disease
50
What are the paraneoplastic syndromes/complications of Lung masses?
- Recurrent laryngeal nerve palsy - Horner's syndrome - Phrenic nerve palsy - Pericarditis - SVC obstruction - P.E (all malignancies)
51
What is Horner's syndrome?
Damage to the sympathetic trunk (arises in spinal cord and ascends to head and neck), due to the presence of a Pancoast tumour in the apex of the lung. symptoms appear on the same side - Miosis (constricted pupil. Light reflex is still present as this is parasympathetic) - Partial ptosis (drooped eyelid or lower eyelid raised due to inactivated superior tarsal muscle) - Anhidrosis (reduced sweating) Flusging - Psuedoenopthalmos (inset eyeball)
52
What is Pulmonary Fibrosis (ILD)?
Scarring of the lung interstitium?
53
What are the causes of Upper Zone Pulmonary Fibrosis?
Allergic Bronchopulmonary ASPERGILLOSIS Alveolitis TB EXTRINSIC ALLERGIC ALVEOLITIS (fungal spores, avian proteins) Ankylosing Spondylitis Sarcoidosis Histiocytosis Occupational e.g. silicosis-egg shell calcification of hilar lymph nodes Pneumoconiosis (dust)
54
What are the causes of Lower Zone Pulmonary Fibrosis?
``` Bronchiectasis RA (others) Asbestos Drugs - Amiodarone - Methotrexate - Sulfasalazine (anti-rheum drugs) - Nitrofurantoin - Some dopamine receptor agonists ``` Idiopathic Interstitial
55
What is Idiopathic Interstitial LD?
A.K.A CRYPTOGENIC FIBROSING ALVEOLITIS 50-60 y, M>f ANA +ve in 30% Rhuem factor 1% Poor prognosis,, 50% 5 year
56
What are the symptoms of Pulmonary Fibrosis?
Systemic: - Flu-like - Weight loss - Malaise arthralgia ``` Cor Pulmonale - sacral oedema - pitting oedema Clubbing Cyanosis Chest pain ``` Dry Cough Fine inspiratory crackles bibasal Exerctional dyspnoea (high R.R)
57
What are the investigations for Pulmonary Fibrosis?
``` Spriometry: restrictive CT: Honeycombing CXR: Ground glass opacity with lower lobe nodule shadows (reduced lung volume) ABG Type 1 RF, Type 2 if severe Biopsy: interstitial pneumonia Reduced transfer factor Broncho-alveolar Lavage: alveolitis ```
58
How is Pulmonary Fibrosis managed?
Give O2 Pulmonary rehab Palliation Transplant
59
What is Asbestosis?
Pleural plaques: - MC - 20-40 year latency - Benign, no malignant changes Diffuse Pleural thickening Asbestosis: - Severity is proportional to length of exposure - 15-30 year latency Mesothelioma: - Malignant disease of the pleura - Progressive SOB, Chest pain, pleural effusion - Give palliative chemotherapy
60
What is Extrinsic Allergic Alveolitis?
Inhalation of allergens e.g. fungal spores or avian proteins resulting in a HYPERSENSITIVITY REACTION ACUTE: alveoli infiltrated with acute inflammatory cells (Fevers, rigors, myalgia, cough, dyspnoea, crackles) CHRONIC: granuloma formation and obliterative bronchiolitis (Dyspnoea (exertional), weight loss, Type 1 resp failure, Cor Pulmonale) FBC, Raised ESR, ABG CXR: U. Zone motelling/consolidation BAL: lymphocytes and mast cells Remove allergens, give O2, Long-term prednisolone
61
What is Allergic Bronchopulmonary Aspergillosis?
Allergy to aspergillus spores (RAST test) ``` Proximal BRONCHIECTASIS EOSINOPHILIA- IgE - Wheeze - Cough - Dyspnoea ``` CXR: - Tram track - Mass - Parahilar ring shadow - Central cystic/varicose STEROIDS and ITRACONAZOLE
62
What are the causes of Bilateral Hilar Lymphadenopathy?
SARCOIDOSIS TB (mycoplasma) Malignancy (lymphoma, carcinoma) Pneumoconiosis Extrinsic Allergic Alveolitis Hystiocytosis
63
What is Sarcoidosis?
MULTISYSTEM GRANULOMATOUS DISEASE
64
What are the features of sarcoidosis?
Conjunctivitis and keratoconjunctivitis Uveitis Facial Nerve Palsy Pituitary dysfunction Upper Zone lung fibrosis with bilateral hilar lymphadenopathy Hepatosplenomegaly Raised Ca2+: renal stones Erythema nodosum Acute arthropathy
65
What can be detected on investigation in Sarcoidosis?
Low Na+-ADH is produced ectopically Raised serum ACE Cytopenia = eosinophillia Raised ESR HyperCa2+ Lymphocytosis and lymphopaenia Treat with Steroids and NSAIDS
66
What is Pleural Effusion?
Build up of fluid in the pleural space Can be Exudate >30g/L or Transudate <30g/L of protein
67
What are the features of Pleural Effusion?
Dullness on percussion Reduced breath sounds and vocal resounnance Reduced chest expansion Non-productive cough Dyspnoea Pleuritic chest pain
68
What are the causes of Transudate Pleural Effusion?
Increased venous pressure ``` HEART FAILURE Hypoalbuminaemia (Liver disease or nephrotic syndrome) Hypothyroidism Meig's syndomre: - Ovarian tumour - ascites - Pleural effusion ```
69
What are the causes of Exudate Pleural Effusion?
Increased capillary leakiness ``` INFECTION (pneumonia, TB, Subphrenic abscess) CT disease (RA, SLE) Neoplasm (Lung cancer, mesothelioma, metastases) Pancreatitis PE Dressler's syndrome Yellow nail syndrome ```
70
What is Light's Criteria?
25-35g/L protein Exudate likely if... Pleural fluid protein/ serum >0.5 Pleural fluid LDH/ serum >0.6 Pleural fluid LDH >2/3 the upper limit of normal serum
71
What else makes Exudative Pleural effusion more likely?
Low Glucose: - RA - TB Raised Amylase: - Acute pancreatitis - Oesophageal perforation Blood staining: - Mesothelioma - TB - PE
72
What does imaging show in Pleural Effusion?
PA CXR - Small: Blunted costophrenic angles - Large: Concave border (unless pneumothorax too in which case flat border) USS guided aspiration and detect seprations Contrast CT to detect cause
73
What is measured in Pleural Fluid analysis?
``` pH Protein LDH Glucose Cytology Microbiology ```
74
How is Recurrent Pleural Effusion managed?
- Aspirate - Pleurodesis: artificially obliterate the pleural space by adhering them together - Indwelling pleural catheter - Relieve symptoms
75
What is Lambert-Eaton syndrome?
Small cell lung cancer Reduced release of acetylcholine Muscle weakness, depressed reflexes and autonomic dysfinction- postural BP drop
76
What are the risk factors for a Pulmonary Embolism?
``` Sex-female Pregnancy Age Surgery Malignancy Oestroge (OCP/HRT) DVT (Prev PE) Immobility Colosal size (high BMI) A Lupus ```
77
What is the pathophysiology of a Pulmonary Embolism?
Risk factors contribute to Virchow's triad: Venous throbosis in the: Popliteal/Femoral/Iliac veins embolises and travels through the venous system -> RA -> RV -> occlude pulmonary a artery causing a: Saddle embolism occluding central arteries or saddle embolus 1. Clot reduces blood flow (V/Q mismatch) - Reduced CO2 delivery to lungs, builds up in blood, detected by medullary chemoreceptors increase R.R - Low O2 detecetd by aortic/carotid receptors increase R.R and H.R 2. Saddle embolus causes PULMONARY HYPERTENSION -> back up of blood to heart -> RH strain 3. Circulation to lung peripheries cut off leading to ischaemia and infarct (although infarct is rare due to lots of collaterals so only really occurs in patients with pre-existing poor flow to lungs e.g. COPD) - irritates somatic endings on parietal pleura causing adrenergic response increase H.R and pleuritic chest pain - ischaemic tissue becomes inflamed and adheres to pleura causing plueral rub and ARDS
78
How does Pulmonary Embolism present?
Triad: - Dyspnoea/SOB - Haemoptysis - Pleuritic chest pain (focal and localised, with each breath) ``` Tachypnoea Tachycardia Cyanosis Hypotension Dizziness and syncope Pyrexia Signs of DVT Pleural rub Increased inflammatory cells -> increased vessel permeability -> ARDS ```
79
What is Well's score?
``` 3 Signs and symptoms of DVT 3 Alternative diagnosis less likely 1.5 Tachycardia 1.5 Immobile >3days/ surgery <4 weeks ago 1.5 Previous DVT/PE 1 Haemoptysis 1 Malignancy ``` >4 means P.E is likely
80
How are Pulmonary Embolisms investigated?
1. Do a CXR to rule out other diagnoses 2. If wellsscore >4 then immediately do CTPA (V/Q if renal failure/contrast allergy) Give LMWH if delayed If <4 do a D-Dimer and do above if +ve 3. ECG - Tachycardia - RBBB+R axis deviation - S1Q3T3 Large S in I Large Q and inverted T in III (Pulmonary angiography is gold standard BUT high risk of complications)
81
How are normal Pulmonary Embolisms managed?
1. LMWH or FONDAPURINUX until INR >2.0 (3.5 in recurrent P.Es) or for 5 days (6 mo in CA patients) 2. Warfarin within 24 hours for at least 3 months (definitely >3 mo if PE unprovoked)
82
How are Massive Pulmonary Embolism with Circulatory Failure managed?
THROMBOLYSIS
83
What is Homan's sign?
Tender calf muscle when leg dorsiflexed
84
How are Pulmonary Embolisms prevented?
Give heparin e.g. deltaparin/Enoxiparin to all immobile patients Stop oestrogen 4 weeks prior to surgery
85
What are the causes of Bronchiectasis?
Post-infective - HIV TB - Measles - Pertussis - Pneumonia Cystic fibrosis Bronchiole obstruction - Cancer - Foreign body Immune deficiency - Selective IgA Allergic Bronchopulmonary Aspergillosis Cilliary Dyskinesia - Kartagener's - Young's RA UC Idiopathic Yellow nail syndrome
86
What is the pathophysiology of Bronchiectasis?
Inflammation Neutrophils, Cytokines NO and O. radicals accumulate Bronchial and prebronchial destruction Elastic tissue lost BRONCHIOLES PERMANENTLY DILATED (would usually taper)
87
What are the features of Bronchiectasis?
OBSTRUCTIVE PATTERN - Persistent cough - Purulent sputum - Intermittent haemoptysis - Clubbing - Wheeze - Coarse insipiratory crepitus
88
What are the complications of Bronchiectasis?
Pneumonia Plueral effusion Pneumothorax Cerebral abscess Amyloidosis
89
What is seen on CT in Bronchiectasis?
Signet rings where the artery looks much denser next to the airy bronchi Clusters of grapes: appear to crowded together Bronchi seen within 1cm of pleura as dilation makes them more visible
90
What is seen on CXR in Bronchiectasis?
Tram tracking: outlining of dilated and thickened bronchi Cystic shadows
91
How is Bronchiectasis managed?
- Physical training - Postural drainage BD - Abx when axacerbated ( - Sometimes bronchodilators - Immunisations - Surgery if localised
92
What is Kartagener's syndrome?
Primary CILLIARY DYSKINESIA-immobility Associated with DEXTROCARDIA and SINUS INVERSUS Causes recurrent SINUSITIS and INFERTILITY
93
What are the causes of ARDS?
Infection: - Sepsis - Pneumonia Trauma Smoking Pancreatitis: - Liver failure Massive blood transfusions Cardio-pulmonary bypass
94
What is the pathophysiology of ARDS?
Lung damage releases inflammatory mediatorys which increases permeability of alveolar capillaries causing fluid to accumulate in the alveoli = NON-CARDIOGENIC PULMONARY OEDEMA
95
What are the features of ARDS?
``` Dyspnoea Tachypnoea Tachycardia Peripheral vasodilation Cyanosis Bilateral FINE INSPIRATORY LING CRACKLES (pulmonary oedema) ```
96
How is ARDS investigated?
- CXR shows bilateral lung infilitration - ABG shows low O2 - Pulmonary artery catheter measures pulmonary capillary wedge pressure which gives an idea of L atrial pressure, if >20mmHg then pulmonary oedema caused by cardiogenic issues
97
What are the diagnostic criteria for ARDS?
Acute Onset (<1 week) CXR shows pulmonary oedema (bilateral infiltration) Non-cardiogenic pulmonary oedema PCWP <19mmHg or NO CONGESTIVE HF Refractory hypoxaemia
98
How is ARDS managed?
ITU Respiratory support: oxygenate/ventilate with CPAP Circulatory support Treat sepsis
99
What is Pulmonary Oedema?
FLUID accumulates in the TISSUE and AIRSPACE of the lung resulting in impaired gas exchange and RESPIRATORY FAILURE CXR is same as in HF
100
What are the causes of Pulmonary Oedema?
CARDIOGENIC: L ventricle fails to remove blood from pulmonary circulation e.g. HEART FAILURE NON-CARDIOGENIC: initial and rapid increase in PUMONARY VASCULAR PRESSURE due to vasoconstriction or blood flow causing parenchyma and vacular injury = LEAKY CAPILLARIES - ARDS - Drowning - Fluid overload - Aspiration - Neurogenic - Allergic - Acute glomerulonephritis
101
What is Idiopathic Pulmonary Arterial Hypertension?
No known underlying cause ``` Risk factors: - Female - 20-40 - FHx (10% A.D) Cocaine ```
102
What are the features of Idiopathic Pulmonary Arterial Hypertension?
Increased pulmonary artery pressure >25mmHg at rest and >30mmHg on exercise Progressive SOB Cyanosis Tricuspid regurgitation on ECHO Raised JVP with prominent A wave Loud O2 R ventricular heave RHF
103
How is What Idiopathic Pulmonary Arterial Hypertension managed?
- Diuretics in RHF - Anticoagulation - Heart-lung transplant - Vasodilator therapy
104
What is the gene mutation in Cystic Fibrosis?
A.R mutation of DELTAF508 on CHROMOSOME 7 (CF Transmembrane Conductance Regulator (CFTR)) 1/25 people are carriers
105
What is the pathophysiology of Cystic Fibrosis?
Dysfunction of the CFTR protein (which is the Cl- ion channel in exocrine glands) means that less Cl- diffuses into secretions from the duct epithelial cells. This reduces the H2O content of the peri-cilliary mucous (reduced osmotic gradient) leading to THICK and STICKY mucous (increased viscosity) Reduced clearance of mucous means it accumulates and obstructs the secretory passageways in the GI, Resp and Genito-urinary tracts This also reduces Cl- ABSORPTION in sweat glands so there is more Cl- in sweat (salty babies)
106
What are the GI tract features of Cystic Fibrosis?
BILIARY TREE-delayed passage of BILE causing LIVER INFLAMMATION resulting in - GALLSTONES - CIRRHOSIS - PORTAL HTN GI TRACT- reduced movement of INTESTINAL contents - CHILDREN/ADULTS this causes DISTAL ILEAL OBSTRUCTION SYNDROME (DIOS) - Neonates causes MECONIUM ILEUS (meconium is retained) resulting in JAUNDICE and RECTAL PROLAPSE PANCREAS-can't secrete DIGESTIVE ENZYMES - STEATORRHOEA - reduced FAT and PROTEIN absorption resulting in FAILURE TO THRIVE and reduced ADEK vitamin absorption - OSTEOPOROSIS due to reduce VIT D the enzymes DEGRADE the pancreas causing scarring and inflammation eventually resulting in - DMT2
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What are the Respiratory tract features of Cystic Fibrosis?
URT: - Nasal polyps - Sinusitis due to retained secretions ``` LRT: Resp failure causing Hypoxia - Cyanosis - Clubbing Cor Pulmonale Pneumothorax Haemoptysis Obstructive Lung disease: hyperinflation and abnormal spirometry Retention of secretions: BRONCHIECTASIS Chronic Productive Cough Bilateral Coarse Crackles Recurrent Chest infections ```
108
What are the Genito-urinary tract features of Cystic Fibrosis?
Vas deferens issues in utero leading to male infertility Female subfertility
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What are the common organisms in Cystic Fibrosis related chest infections?
- Staph Aureus - Psuedomonas Aeruginosa - Aspergillus - Burkholderia cepacia
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What are the investigations for Cystic Fibrosis?
- genetic screening - Cl- IN SWEAT > 60MMO/L (Cl>Na) - Faecal elastase - Annual Glucose Tolerance Test
111
How is Cystic Fibrosis managed?
- Ursodeoxycholic acid in liver inflammation - Pancreatic enzyme supplements - Supplements (high fat and calorie diet) - Chest physio BD - Antibiotics - Vaccinations
112
What is a Pneumothorax?
Presence of gas in the pleural space
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What are the types of Pneumothorax?
Primary: no underlying lung pathology Secondary: underlying lung disease Closed: Pleuritic cavity pressure < atmospheric pressure Open: Air can enter the chest from the outside Tension: Pleuritic cavity pressure > atmospheric pressure - One way valve formed between damaged tissue so gas continues to enter - this significantly impairs respiration and/or blood circulation by putting pressure on the mediastinal/thoracic structures
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What are the features of Pneumothorax?
- Chest pain - Shortness of breath - Reduced breath sounds on that side - Hyperresonance - Reduced vocal resonance and tactile fremitus '99'
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How are Pneumothoraces managed?
PRIMARY: Small <2cm: Monitor Large: Syringe and Chest drain into 2nd intercostal space mid clavicular line SECONDARY: Small: Syringe and Chest drain Surgery: Pleurodesis- stick pleura together or Pleurectomy-remove the pleural membranse Will fail to inflate if there is an injury to a right main bronchus
116
What is Atelectasis?
BLOCKAGE or INCREASED PRESSURE in or around BRONCHIOLES BASAL ALVEOLAR COLLAPSE causing COLLAPSE OF 1 or MORE LOBES RESPIRATORY DIFFICULTY (Tachypnoea and Pleural Effusion) AIRWAYS OBSTRUCTED BY BRONCHIAL SECRETIONS with REDUCED OR ABSENT GAS EXCHANGE AIR IS TRAPPED Causes by: - TB - Post-op - Lack of surfactant in infants
117
What are the features of Tension Pneumothorax?
- Respiratory distress - Tachycardia - Cyanosis - Reduced consciousness Displacement of Apex HB Resonance on tapping the sternum Trachea displaced away from the collapse JVP
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What are the features of an Obstructive respiratory disease pattern?
Reduced FEV1 FVC normal or a bit reduced FEV1/FVC= REDUCED e.g. Asthma, COPD, Bronchiectasis
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What is Bronchiolitis Obliterans?
Popcorn lung Obstruction of smallest airways due to inflammation
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What are the feature of a Restrictive respiratory disease pattern?
Reduced FEV1 Reduced FVC equally FEV1/FVC= NORMAL OR RAISED e.g. Fibrosis (aspestosis, sarcoidosis), ARDS Neuromusclar and Kyphoscoliosis
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What are the causative organisms for TB?
MYCOBACTERIUM TUBERCULOSIS Bovis Africanum Non-mobile, rod bacili, obligate aerobe
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What is the pathophysiology of TB?
Mycobacterium ENGULFED by ALVEOLAR MACROPHAGES but can't kill so continue to multiply Primary complex of TUBERCLE LADEN MACROPHAGES CASEATING GRANULOMA Local drainage into HILAR LYMPH NODES Lymphocytes and epitheloid + LANGHERHAN'S GIANT CELLS GHON COMPLEX: INFECTION IS CONTAINED
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What are the features of Primary and Milliary TB?
``` Immune destruction of the lung - Fever - Cough: haemoptysis - Night sweats - Weight loss - Malaise - Breathlessness - Crackles - Pleural Effusion - Cavitation and fibrosis Seen on CXR ```
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What conditions can reactivate TB?
- Diabetes - CKD - Haem malignancy - Organ transplant - Tumour necrosis - Silicosis - Low body weight - HIV - Substance abuse and IVDU - Immunosupression i.e. STEROIDS
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What are the extra-pulmonary features of Secondary TB?
- Larynx - Lymph nodes -> cervical SCROFULODERMA - CNS -> TB meningitis - Renal spread to LUT - GI due to swallowing - Bones and Joints -> Vertebral bodies -> Pott's
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What is Pott's (TB)?
In the spine
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How is TB managed?
Rifampicin Isonazid Pyroxidine Ethambutol 3 or 4 for 2/12 18/12 if CNS
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What are the diagnostic tests for TB?
- NAAT and chromotography - ACID FAST - ZIEHL NEILSEN stain - Auramine stain - Culture is gold standard - Tuberculin Sensitivity Test on skin (delayed-type hypersensitivity reaction) - Gastric aspirates in children
129
Define: stridor
narrow or obstructed upper airways, sounf od turbulent airflow through larynx or bronchial tree
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What is Obstructive Sleep Apnoea?
Throat muscles intermittently relax in sleep blocking airways, breathing repeatedly stops and starts
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What are the predisposing factors for Obstructive Sleep Apnoea?
- MARFAN'S - large tonsils - Obesity -> loswe weight - Macroglossia e.g. in Acromegaly, Hypothyroidism, Amyloidosis -> Can manage with intraoral devices
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What are the consequnces of Obstructive Sleep Apnoea?
Daytime sleeping: EPWORTH sleepiness scale, multi-sleep latency test Reduced arousal response in REM HTN Compensated RESPIRATORY ACIDOSIS
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What is Thoracoabdominal movement paradox?
Reverses inspiration/expiration chest contractions: abdomen moves weirdly

FINALS (13 decks)

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