PULMONOLOGY Flashcards
What are the causes of COPD?
Smoking
a-1 antitrypsin deficiency
Dust e.g. cadmium, coal, cotton, cement, grain
What are the symtoms of COPD?
Cough (productive)
Wheeze
Dyspnoea
What are the signs of COPD?
Tachypnoea Accessory Muscles Hyperinflation Hyperresonence Reduced expansion Reduced breath sounds e.g. over bullae Reduced corticosternal distance Cyanosis Cor pulmonale (raised JVP)
What are the complications of COPD?
Acute exacerbations (+/- infection) Respiratory failure Polycythaemia abnormal increase in Hb Pneumothorax due to ruptured bullae Lung carcinoma
What are the stages of COPD?
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
What are the signs of COPD on CXR?
Hyperinflation
Bullae
Flat hemidiaphragm
Hyperlucent lung fields
What are the investigations for COPD?
- Spirometry
- FBC
- CXR
- BMI
How is COPD managed?
- Stop smokinh
- Flu vaccine (annual) and pneumococcal vaccine (one-off)
- SABA OR SAMA
- FEV1 > 50% LABA or LAMA
FEV1 <50% LABA + ICS or LAMA - Oral theophylline (reduce if giving macrolide or fluoroquinolone)
Persistant exacerbation/ breathlessness: LABA+ICS_LAMA
Mucolytics for productive cough
What can improve survivial in COPD?
- Stop smoking
- Lung volume reduction surgery
- Long term O2 therapy
When should long-term O2 therapy be considered?
FEV1 <30% Cyanosis Polycythaemia Peripheral oedema Raised JVP PO2 <92% on room air
When should long-term O2 therapy be offered?
2 blood gasses, 3 weeks apart
pO2 < 7.3kPA or 7.3-.8kPA + 1 of…
- Secondary polycythemia
- Nocturna; hypoxaemia
- Peripheral oedema
- Pulmonary HTN
What microorganisms cause acute exacerbations of COPD?
H. Influenzae
S. Pneumoniae
Maroxella Catarrhalis
30% are viral
How are exacerbations of COPD managed?
Nebbed bronchodilator
7-14 days of prednisolone
Abx ONLY if sputum is purulent OR clinical signs of pneumonia
NIV when pH 7.25-35
What are ‘pink puffers’?
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
What are ‘blue bloaters’?
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
What is Asthma?
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
What are the risk factors for Asthma?
Atopy: eczema, hayfever Not breast fed Maternal smoking Very clean house Multiple siblings Hygiene Aspirin Occupational
How does asthma present?
Widespread Expiratory Polyphonic Wheeze
Hyperinflated chest-hyperresonnance
Obstruction
Nocturnal cough
What are the investigations for Asthma?
PEF
Spirometry
FEV1(reduced)/FVC(normal) <70%
Reversed when given SABA (improvement >12% and increase in volume >200ml
How is Asthma managed?
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
How is acute asthma classified?
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)
How is acute asthma managed?
Nebulise 5mg salbutamol through oxygen
Teotropium Bromide
Oral prednsiolone (continue 40-50mg 5 days after) or IV hydrocortisone
Magnesium sulphate IV
What is Pneumonia?
Inflammation of the alveoli in a lobar pattern
How is Pneumonia classified?
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
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
What are the non-infective causes of Pneumonia?
- Aspiration Pneumonia
- Idiopathic interstitial Pneumonia
What is Streptococcal Pneumoniae Pneumonia?
Majority of cases
High fever
Rapid onset
Rusty sputum
>60 y/o
Associated with herpes virus
Vaccine available
What is Staphylococcal Pneumoniae Pneumonia?
After recent flu
IVDU
What is Haemophilus Influenzae Pneumonia?
COPD
Dry cough
What is Klebisiella Pneumoniae Pneumonia?
Alcoholics
Diabetics
‘Red-current jelly’ sputum
Upper lobes
Aspiration
Causes lung abscesses and empyema
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
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
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
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
What is Chlamydia Psittacosis Pneumonia?
Parrots, poultry and sheep
Human to Human
Tetracyclines
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
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
What is Idiopathic Interstitial Pneumonia?
Non-infective pneumonia e.g. Cryptogenic organising pneumonia (bronchiolitis due to RA or amiodarone) can cause ground-glass opacity
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
What are the risk factors for Lung Cancer?
SMOKING (x10)
Asbestos (x5)
(Arsenic, Radon, Nickle, Chromate)
What are the types of Lung Cancers?
Small Cell 15%
Non-Small cell:
- Squamous 35%
- Adenocarcinoma 30%
- Large-cell 10%
- Bronchial adenoma
How are Lung Cancers investigated?
- Contrast CT
- CXR (10% are reported as normal)
- Peripheral nodule
- Hilar enlargement
- Consolidation
- Lung collapse
- Pleural effusion
- Boney secondaries - Bronchoscopy to biopsy
- PET scan for Non-Small Cell to establish eligibility for treatment
- Cytology
- Sputum
- Pleural fluid - Lung function tests
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)
What are the paraneoplastic syndromes and complications for Small-Cell Lung Cancer?
- ADH (SIADH) hyponatreamia
- ACTH cushing’s
- Lambert-Eaton syndrome is like myesthenia
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)
What are the features, paraneoplastic syndromes and complications of squamous cell lung cancers?
Central, cavitating tumours
Finger clubbing
PTH-rp -> hypercalcaemia
TSH -> hyperthyroid
What are the features of Adenocarcinomas?
Typically peripheral
Most common in non-smokers
What are the features and paraneoplastic syndromes of Large-cell lung cancers?
Typically peripheral
Anaplastic, poor differentiation and poor prognosis
Secrete B-HCG
Gynaecomastia
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
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)
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)
What is Pulmonary Fibrosis (ILD)?
Scarring of the lung interstitium?
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)
