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FCM Matrix > Resp > Flashcards

Resp Flashcards

1
Q

What does a sputum sample film show in acute bronchitis?

A

Neutrophil granulocytes (inflammatory WBCs)

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2
Q

When is Abx indicated in acute bronchitis?

A
  • When bacterial infection is suspected.
  • CRP 20 - 100mg/l (delayed prescription
  • CRP > 100mg/l (Abx therapy)
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3
Q

If Abx is indicated in acute bronchitis, what is the 1st line?

A

Doxycycline (5-day course)

  • X pregnancy, uses amoxicillin (500mg TD for 5 days)
  • young people (amoxicillin)
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4
Q

What pathogen causes influenza?

A

RNA virus - orthomyxoviridae

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5
Q

How is influenza diagnosed?

A

Clinical diagnosis

- viral culture - PCR

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6
Q

What are the symptoms of influenza?

A
  • Coryzal symptoms
  • Fever
  • Headache
  • Non-productive cough
  • Sore throat
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7
Q

Management of influenza and indication for medication

A

Antivirals:
Selective use of antivirals : oral oseltamivir and inhaled zanamivir
Indication:
1) if able to start treatment within 48 hours of symptoms onset
2) Known circulation of virus in community
3) High-risk : pregnant, obese, > 65 + < 6 y.o, immunocompromised, comorbidities

Conservative:

  • analgesia
  • increase fluid intake
  • rest
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8
Q

What is croup?

A
  • Inflammation of the upper respiratory tract
  • acute laryngotracheitis
  • due to viral infection
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9
Q

What organism is most responsible for croup?

A
  • Parainfluenza

- RSV

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10
Q

What are the symptoms of croup?

A

Seal-like barking cough

  • runny nose
  • fever
  • stridor
  • voice hoarseness
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11
Q

How do you diagnosis croup?

A

Clinical diagnosis

- Significant resp impairment ( O2 <95%)

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12
Q

What is the management of croup?

A

Conservative:

  • ensure patient remains calm ; agitation can lead to increased o2 demand
  • paracetamol (for fever)

Medical:
- Whilst awaiting hospital admission: give O2, oral dexamethasone

  • Mild illness (no hospital admission): single dose corticosteroid (oral dexamethasone)
  • -> symptoms usually resolve within 48 hours
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13
Q

Is RSV contagious?

A

Yes

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14
Q

What is the most common complication RSV?

A

Bronchiolitis

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15
Q

What age group is most affected by RSV?

A
  • Babies in 1st year of life

- Usually 3-6 months

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16
Q

How is RSV spread?

A

air droplet

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17
Q

What are the RSV symptoms?

A

Cold-like symptoms:

  • low grade fever
  • wheezing
  • chest congestion / rhinorrhea
  • SOB
  • Cough
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18
Q

What is the management of RSV?

A
  • Conservative : observation + hydration

- Medical: Bronchodilators, alpha agonists

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19
Q

What is bacterial pneumonia?

A
  • bacterial mediated inflammation

- infection of the lung tissue in which the alveoli become filled with MO, fluid & inflamm cells

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20
Q

What are the most common microorganism causing bacterial pneumonia?

A
  • streptococcus pneumonia
  • H.influenza
  • staphylococus aureus
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21
Q

What are the key symptoms for bacterial pneumonia?

A
  • Green Productive Cough*
  • SOB
  • Fever
  • Chest pain
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22
Q

What are the key signs for bacterial pneumonia?

A
  • Increased tactile & vocal fremitus
  • Dullness to percuss
  • Bronchial breath sounds
  • Late inspiratory crackles
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23
Q

Investigations for pneumonia?

A
  • CXR : to identify location and extent

- CRP : inflammation

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24
Q

What score is used to admit pt to hospital with pneumonia?

A

CRB-65
> 3 = urgent admission
> 2 = hospital management
0 = conservative management at home

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25
Q

Management of bacterial pneumonia?

A

Medical

Abx:

  • co-amoxiclav (hospital)
  • amoxicillin = 500mg TD for 5/7 (home) (1st line)
  • oral doxycycline = (penicillin allergy)

Oxygen for hypoxia

Long-term: pneumococcal vaccine

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26
Q

What are the key symptoms for viral pneumonia?

A

Non-productive cough

Systemic symptoms:

  • fever
  • runny nose
  • myalgia
  • fatigue
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27
Q

What are the investigation findings for viral pneumonia?

A
  • Viral PCR

- CXR : more likely bilateral consolidation

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28
Q

Management of viral pneumonia

A

Conservative:

  • fluids & oxygen therapy
  • flu vaccine for high risk groups

Medical:
- self-resolving
Antiviral depending on the causative organism:
- Tamiflu = oseltamavir, influenza = zanamavir
- Herpes & VZV = acyclovir
- RSV = Ribavarin

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29
Q

What is acute bronchiolitis?

A
  • Acute viral infection of the LRT

- Characterised by epithelial destruction, cellular oedema & airwary obstruction by inflamm debris & mucus

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30
Q

Most common cause of bronchiolitis

A

RSV

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31
Q

what are the symptoms of acute bronchiolitis?

A
  • Fever
  • Cough
  • Poor feeding
  • Apnoea
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32
Q

What are the signs of acute bronchiolitis?

A

Clinical diagnosis: < 2 presenting with 1-3 days hx of coryzal symptoms

  • persistent cough
  • tachypnoea or chest recession (both)
  • wheeze or crackles OA (both)
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33
Q

Investigation for acute bronchiolitis

A

CLINICAL DIAGNOSIS

  • check 02 sats
  • CXR not recommended unless evidence of deterioration
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34
Q

Management of acute bronchiolitis

A

Conservative:
- self-limiting , can be managed at home

Medical:

  • O2 if sats < 92%
  • CPAP if resp failure
  • Ribavarin (RSV)
  • oral corticosteroids (hx of wheeze)

Referral:

  • RR > 60 breaths/min
  • inadequate fluid intake/ signs of dehydration
  • if child is < 3 months or born prematurely.
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35
Q

What is acute epiglottitis?

A

Cellulitis of the supra-glottis - may cause airway compromise.
- Airway emergency in children

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36
Q

What is the most common cause for acute epiglottitis?

A

H.Influenza

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37
Q

What are the symptoms of acute epiglottitis?

A
  • Sore throat
  • Stridor
  • Tripod position : lean forward + extending neck.
  • Dysphagia
  • Fever
  • Drooling
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38
Q

What are the signs for acute epiglottitis?

A

High - pitched inspiratory wheeze

* DO NOT EXAMINE THROAT*

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39
Q

What are the investigation finding for acute epiglottitis?

A

Lateral neck radiograph - THUMB SIGN

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40
Q

What is the acute management for acute epiglottitis?

A

1st line = contact paediatrics + arrange same day review & admission (anaesthetists)

  • Secure airway + oxygen
  • IV Abx
  • Corticosteroids (dexamethasone)

once stable and extubated –> 1st line : oral abx (amoxicillin)

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41
Q

What is the surgical management of acute epiglottitis and when is it indicated?

A

Tracheostomy (compromise of airway)

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42
Q

What are the complications of acute epiglottitis?

A
  • Abscess formation
  • Sepsis
  • Pneumothorax
  • Meningitis
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43
Q

What is pertussis?

A
  • Whooping cough
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44
Q

What organism causes pertussis?

A
  • Bordetella Pertussis
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45
Q

How is pertussis transmitted?

A
  • Sneeze or cough (airborne)
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46
Q

What is the pathophysiology of pertusis?

A
  • BP toxins anchor to the epithelium.
  • Toxin paralyse the cilia –> excess mucus build up
  • Mucus build up triggers violent cough reflex (coughing spells, “paroxysms”)
  • Swollen airways cause whooping noise
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47
Q

What are the 3 phases of symptoms called in Pertussis?

A

1st phase = catarrhal

  • runny nose
  • malaise
  • sore throat
  • low-grade fever
  • dry cough

2nd phase = paroxysmal (1-6 weeks)

  • short expiratory burst followed by inspiratory gasp (whoop)
  • thick mucus secretions

3rd phase = convalescent (3 months)
- gradual improvements in cough frequency + severity

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48
Q

What are the key symptoms should you suspect for pertussis?

A

Acute cough > 14 days w/ no apparent cause w/:

  • paroxysmal cough
  • inspiratory whoop
  • Post-tussive vomiting
  • undiagnosed apnoeic attack
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49
Q

How to diagnose pertussis?

A

Nasopharyngeal swab

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50
Q

What is the medical management of pertussis?

A

1st line:

  • macrolide abx : clarithromycin, erythromycin for pregnant women
  • co-trimoxazole if contra-indicated

House hold prophylaxis
< 6 month - admission to hospital

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51
Q

How long to isolate with pertussis?

A
  • 21 days after symptoms onset

- 48 hours after abx

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52
Q

What is empyema?

A

Defined as the presence of frank pus in the pleural space.

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53
Q

What are the common infection causing empyema?

A
  • Due to post pneumonia
  • Anaerobic, staph & gram-negative infections
  • Klebsiella: alcoholism, currant jelly-like sputum.
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54
Q

What is the aetiology of empyema?

A

free flowing fluid which becomes infected

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55
Q

What are the symptoms of empyema?

A
  • SOB
  • Fever
  • Pleuritic chest pain
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56
Q

What are the signs of empyema?

A
  • Tachypnoea
  • Reduced breath sounds
  • Dullness to percuss
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57
Q

What are the investigation findings of empyema?

A

CXR: blunting of the costophrenic angle or effusion on affected side
CRP & WCC- raised in infection

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58
Q

What investigation is diagnostic for empyema?

A

Thoracentesis: aspiration of the frank pus

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59
Q

What is the management of empyema?

A

+ 1st line
- IV empirical abx:
- Community = Ceftriaxone + metronidazole
- Hospital = vancomycin + cefepime + metronidazole
+ Chest tube drainage
+ Fluid resuscitation

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60
Q

What is chronic bronchitis?

A

Long-term inflammation of the lining of the bronchial tubes

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61
Q

What are the symptoms of chronic bronchitis?

A
  • Cough
  • Sputum
  • Fatigue
  • SOB
  • Chest discomfort
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62
Q

What is the 1st line for infective

exacerbation of chronic bronchitis?

A

Amoxicillin or clarithomycin

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63
Q

What is emphysema?

A

Condition causes SOB due to damaged alveoli in the lungs

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64
Q

What are the signs and symptoms of emphysema?

A
  • SOB (progressive & at rest)
  • Fatigue
  • Central & peripheral cyanosis
  • Persistent wheeze
  • Productive cough
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65
Q

What are the signs of emphysema?

A
  • ” Pink puffers”
  • Accessory muscle use
  • Barrel chest
  • Hyper-resonance on percussion
  • Absent or quiet breath sounds on auscultation
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66
Q

What are the investigation for emphysema?

A
  • Bloods: Serum Alpha 1-antitrypsin
  • CXR
  • Sputum culture
  • Lung function test
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67
Q

What is the management for emphysema?

A

Conservative:

  • Smoking cessation
  • Pulmonary rehabilitation
  • Nutrition therapy

Medical:

  • Oxygen therapy
  • Bronchodilators (SABA/SAMA, LABA/LAMA)
  • Inhaled corticosteroids
  • Antibiotics – of bacterial infection

Surgery:

  • Lung volume reduction surgery
  • Lung transplant
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68
Q

What does COPD stand for?

A

Chronic Obstructive Pulmonary Disease

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69
Q

What is COPD?

A
  • Airflow limitation

Group of progressive lung disease including chronic bronchitis & emphysema (treatable but not curable)

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70
Q

What is the pathophysiology of COPD?

A

CB: damage to endothelium impairing the mucociliary response to clear mucus & bacteria – airway deformation & narrowed lumen

EMP: enlargement of alveoli, leading to decline in gas exchange

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71
Q

What deficiency causes COPD?

A

Alpha 1-trypsin

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72
Q

What are the symptoms for COPD?

A
  • SOBOE (progressive)
  • Chronic cough
  • Regular sputum production
  • Wheeze
  • Weight loss
  • Fatigue
  • PND
  • Ankle swelling (cor pulmonale)
  • Chest pain
  • Haemoptysis
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73
Q

What are the signs for COPD?

A
  • Frequent LRTI
  • Cyanosis
  • Raised JVP
  • Cachexia
  • Barrel chest
  • Accessory muscle use
  • Purse lip breathing
  • Crackles OA
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74
Q

How is COPD diagnosed?

A

Clinical features + spirometry

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75
Q

What investigations are carried when suspecting COPD?

A
  • Spirometry
  • CXR
  • ABG
  • Sputum culture
  • Serum alpha 1-trypsin
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76
Q

What spirometry findings confirms persistent airflow obstruction?

A

A post-bronchodilator FEV1/FVC < 0.7

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77
Q

How is the severity of COPD classified?

A

Post-bronchodilator FEV1/FVC < 0.7

FEV1 (of predicted)
> 80% : Stage 1 - Mild - symptoms should be present to diagnose COPD in these patients

50-79% : Stage 2 - Moderate

30-49% : Stage 3 - Severe

< 30% : Stage 4 - Very severe

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78
Q

What are CXR findings in COPD?

A
  • Hyperinflation
  • Bullae
  • Flat haemodiaphragm

(exclude cancer)

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79
Q

What is the medical management algorithm for COPD?

A

See algorithm on PASSMED

1) SOB + exercise limitation : SABA/SAMA
- > SAMA : Ipratropium
- > SAMA: 1st line in new diagnosis

2) No asthmatic features: LABA + LAMA (for day-day symptoms)

3) Asthmatic features: LABA + ICS
- -> LABA + LAMA + ICS – if pt’s day-day symptoms is affecting QOL or 1 serious hospitalisation or 2 moderate exacerbations

4) ICS – increased risk (including pneumonia)
5) Other add on treatments : oral corticosteroids, oral theophylline, oral mucolytic therapy, oral anti-tussive therapy, prophylactic antibiotic therapy -> azithromycin, macrolides, phosphodiesterase-4 inhibitors

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80
Q

What are the asthmatic features when treating COPD?

A

1) any previous, secure diagnosis of asthma or of atopy
2) a higher blood eosinophil count
3) substantial variation in FEV1 over time (at least 400 ml)
4) substantial diurnal variation in peak expiratory flow (at least 20%)

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81
Q

What are the complications of COPD?

A
  • Secondary polycythaemia : Increased haematocrit due to long-term hypoxia
  • Respiratory acidosis: indicates BiPAP
  • Recurrent chest infections
  • Cor pulmonale
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82
Q

What can a large bullae in CXR in COPD mimic?

A

Pneumothorax

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83
Q

What type of bacteria is Haemophilus influenza?

A
  • Gram negative rod
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84
Q

How do you manage acute exacerbation of COPD?

A

1) Nebulised salbutamol
2) Ipratropium (SAMA) + oxygen
3) Steroids (prednisolone)
4) Abx (amoxicillin)

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85
Q

What is asthma?

A

Chronic respiratory condition associated with airway inflammation and hyper-responsiveness.

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86
Q

What is asthma associated with?

A

Eczema + Hay fever

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87
Q

What features is required for the classification of moderate asthma?

A

1) PEFR 50-75% best or predicted
2) Speech normal

3) RR < 25 / min
4) Pulse < 110 bpm

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88
Q

What features is required for the classification of severe asthma?

A

1) PEFR 33 - 50% best or predicted
2) Can’t complete sentences

3) RR > 25/min
4) Pulse > 110 bpm

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89
Q

What features is required for the classification of life-threatening asthma?

A

1) PEFR < 33% best or predicted
2) Oxygen sats < 92%

3) ‘Normal’ pC02 (4.6-6.0 kPa)
4) Silent chest, cyanosis or feeble respiratory effort
5) Bradycardia, dysrhythmia or hypotension
6) Exhaustion, confusion or coma

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90
Q

What are the features of klebsiella pneumonia?

A
  • RF: alcohol and diabetes
  • ‘red-currant jelly’ sputum
  • Upper lobe
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91
Q

What are the types of influenza and how does affect treatment ?

A

Complicated :

1) CNS involvement or exacerbation of underlying condition
2) Antivirals : oseltamivir or zanamivir

Uncomplicated :

1) generalised symptoms
2) ONLY oseltamivir

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92
Q

What are the common symptoms associated with asthma?

A
  • Wheeze
  • Chest tightness
  • SOB
  • Cough
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93
Q

What are the clinical signs associated with asthma?

A
  • OBS : HR > 110, RR > 25
  • Tracheal deviation
  • Widespread wheeze OA
  • Chest deformity/ hyperinflated chest ( chronic asthma)
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94
Q

When do symptoms of asthma commonly present (timing)?

A
  • Worse at night
  • Early in the morning
  • In response to exercise
  • Allergen exposure
  • Cold air
  • After taking aspirin or BB
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95
Q

What is the management algorithm for asthma in adults?

A

1) SABA
2) SABA + ICS (low dose)
3) SABA + ICS + LABA or MART
4) SABA + ICS (increase dose) + LTRA +/- LABA
5) Refer

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96
Q

What are the examples of drug used in asthma for each class of drugs?

A 
SABA = salbutamol
ICS = belclamethasone
LTRA = montelukast
LABA = salmeterol
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97
Q

When is ICS indicated in asthma?

A
  • Pt uses SABA > 3 x week
  • asthma symptoms > 3 x week
  • woken at night due to symptoms
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98
Q

When is SABA indicated in asthma?

A
  • Symptomatic asthma
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99
Q

Immediate management of acute asthma

A

1) Admission to hospital
2) Oxygen
3) Nebulised SABA
4) Corticosteroid
5) Ipratropium bromide
6) IV magnesium sulphate
7) IV aminophylline

100
Q

What does normal PaCO2 in acute asthma indicate?

A
  • Exhaustion

This is classified as life-threatening

101
Q

When is chest X-RAY indicated in acute asthma?

A

Not routinely done”

  • life-threatening asthma
  • suspected pneumothorax
  • failure to respond to treatment
102
Q

What investigations are considered in asthma?

A

1) Spirometry : < 70 % in FEV1/FVC suggests airflow limitation
- -> normal spirometry does not r/o asthma
- -> BDR: confirms diagnosis, > 12% improvement, with an increase in volume of > 200ml is positive result

2) Peak flow : > 20% variability is positive result
- ->support diagnosis

3) FENO testing : esonophilic airway limitation support diagnosis (> 40 ppb)
4) Allergy testing

103
Q

What is sleep apnoea?

A

the interruption of sleep as a result of a narrowing of the throat

104
Q

What is the pathophysiology of OSA?

A
  • When we sleep out throat muscles generally relax and become floppy

In OSA - muscles become excessively relaxed and floppy

  • -> results in partial or complete obstruction of the airway
  • -> partial = snoring
105
Q

What symptoms can indicate sleep apnoea?

A
  • Loud snoring
  • Day time sleepiness
  • impaired concentration
  • Unrefreshed on waking
  • Witnessed apnoea: choking noises while sleeping
106
Q

What should you examine for in sleep apnoea?

A
  • Enlarged tonsils
  • small jaw
  • nasal blockage
107
Q

What questionnaire is helpful in diagnosing OSAS?

A

Epsworth sleepiness questionnaire

108
Q

What investigations can be carried out in sleep apnoea?

A
  • Polysomnography : sleep study to measure apnoea /hypoapnoea episodes
  • Lung function
  • Endoscopy
109
Q

What is the medical management of sleep apnoea?

A

1st line = CPAP (severe)

2nd line = Intra-oral if CPAP is not tolerated

110
Q

What conservative management can you advice for sleep apnoea?

A
  • weight loss
  • exercise
  • smoking cessation
  • nasal decongestants
  • sleep on side
111
Q

What is Pulmonary Embolism?

A

One or more emboli from a thrombus in the vein, lodged in and obstructing the pulmary arterial system causing resp dysfunction

112
Q

What are the types of PE?

A

Provoked PE: associated with transient RF

Unprovoked PE: absence of transient or persistent RF

113
Q

What are the risk factors for PE?

A

1) Immobilisation
2) Surgery in the last 4 weeks
3) Previous DVT/PE
4) Malignancy
5) Increased coagulability

114
Q

What is the triad of symptoms for PE?

A

1) SOB
2) Chest pain
3) Haemoptysis

  • cyanosis
  • unilateral leg swelling
  • syncope
115
Q

Signs of PE

A
  • Tachycardia
  • RR > 20
  • Raised JVP
  • Pleural rub
  • Hypotension
116
Q

What score is used for PE?

A

Wells score :

1) DVT
2) PE is #1 diagnosis OR equally likely
3) Heart rate > 100
4) Immobilization at least 3 days OR surgery in the previous 4 weeks
5) Previous, objectively diagnosed PE or DVT
6) Haemoptysis
7) Malignancy w/ treatment within 6 months or palliative

117
Q

What is the 1st line investigation for PE?

A

CTPA

> 4 points on Well’s

118
Q

When is CTPA contraindicated?

What is 1st line in this case?

A

Renal impairment - due to contrast
Pregnancy

1st line in above = V/Q scan

119
Q

When do you offer D-dimer test?

A

< 4 points on Well’s

120
Q

If CTPA is negative, what is the next step if DVT is suspected?

A

Proximal Leg USS

121
Q

What ECG changes is associated with PE?

A

1) Large S wave in lead I
2) Q wave in lead III
3) Inverted T-wave in lead III
* S1Q3T3*

4) RBBB
5) RAD

122
Q

What might you see on an ABG in PE?

A

Respiratory alkalosis

123
Q

If a pt has PE + hypotension, what would you do?

A

Thrombolyse (alteplase)

124
Q

What is 1st line medication in PE without hypotension?

A

DOAC - apixaban or rivaroxaban

125
Q

What is another criteria used in PE?

A

pulmonary embolism rule-out criteria (the PERC rule)

  • -> all the criteria must be absent to have negative PERC result, i.e. rule-out PE
  • -> this should be done when you think there is a low pre-test probability of PE, but want more reassurance that it isn’t the diagnosis
  • -> a negative PERC reduces the probability of PE to < 2%
  • -> if your suspicion of PE is greater than this then you should move straight to the 2-level PE Wells score, without doing a PERC
126
Q

What is the PERC?

A

Criteria:

1) Age > 50
2) HR > 100
3) O2 < 94%
4) Previous DVT or PE
5) Recent surgery or trauma in the past 4 weeks
6) Haemoptysis
7) Unilateral leg swelling
8) Oestrogen use

127
Q

If Well’s score is > 4 points, what does it mean and what is the algorithm?

A

PE likely:

1) CTPA
2) Delay in CTPA, interim anticoag until scan

128
Q

If Well’s score is < 4 points, what does it mean and what are the next steps?

A

PE unlikely:

1) D-dimer test
- -> If + , CTPA
- -> if - , stop anticoag and consider alternative diagnosis

129
Q

What is the possible CXR finding in PE?

A
  • Typically normal

- Possible wedge-shaped opacification

130
Q

What is the interim anticoag in PE?

A

DOACs - Rivoraxaban or Apixaban

131
Q

What is 1st line management for confirmed PE?

A
  • DOAC
132
Q

What medication is used if DOAC is not suitable in PE?

A

LMWH followed by Vitamin K antagonist (Warfarin)

133
Q

Medication for PE if renal impairment ?

A

LMWH

134
Q

How long should patient have anticoagulation in PE?

A

at least 3 months

  • Provoked: stopped after 3 months
  • unprovoked: continue for 3 more months (6 months in total)
135
Q

Which score is used when starting and continuing anticoagulation in PE?

A

HAS-BLED

136
Q

What is Cor Pulmonale?

A

Right ventricle failure through pulmonary artery htn due to lung disorder

137
Q

What is the pathophysiology of Cor Pulmonale?

A
  • Result of high BP in pulmonary arteries
  • increased afterload
  • right ventricle is good volume pump and not pressure pump
  • so hypertrophy of the right ventricle
  • decreased right ventricle output results in decreased left ventricle filling
  • therefore, reduced CO
138
Q

What can cause Cor Pulmonale?

A
  • PE
  • Acute respiratory distress syndrome
  • Chronic : COPD
139
Q

What are the symptoms of COR Pulmonale?

A
  • SOB
  • Chest pain
  • Fatigue
  • DIzziness
  • SOBOE
  • Ankle swelling
140
Q

What are signs associated with Cor Pulmonale?

A
  • Left parasternal heave* (sign of right ventricular hypertrophy)
  • S3, S4 + pansystolic murmur
  • Intercostal recession
  • Systolic bruits
  • Raised JVP
  • Increased HR
  • Crackles
141
Q

What are the ECG findings associated with Cor Pulmonale?

A
  • Increased P wave amplitude
  • PR depression
  • RAD
142
Q

What investigation can be carried out for Cor Pulmonale?

A

CXR = rught artial size + pulmonary artery enlargement

CTPA/MRI of the chest

V/Q scan = PE or RHF

143
Q

What is the management for Cor Pulmonale?

A

Treat the underlying cause

Medical:

  • Diuretics: furosemide
  • long-term O2 therapy
  • Vasodilators: nifedipine & diltiazem

Surgical:
- Heart or lung transplant = last resort

144
Q

Painful rash + cough = diagnosis?

A

sarcoidosis

145
Q

What pathogen is the most common cause for fungal pneumonia?

A

Pneumocystis Jiroveci

Typically seen in patients with HIV

146
Q

What are the symptoms and signs associated with Pneumocystis Jiroveci?

A
  • dry cough
  • SOB
  • Fever
  • exercise induced desaturations
  • absence of chest signs
147
Q

What medication can be used in fungal pneumonia?

A
  • Azole based antifungals
    e. g. voriconazole
  • Always discuss with micro when suspecting fungal pneumonia
148
Q

What is pneumocystis pneumonia?

A
  • fungal infection in one or both lungs

- common in people with weakened immune system (AIDs)

149
Q

What is the treatment for pneumocystis jiroveci?

A
  1. Co-trimoxazole
  2. for severe disease: IV or high dose orally
    - IV pentamidine
  3. steroids if hypoxic
150
Q

What is pneumocystis jiroveci also known as?

A

Pnuemocystis carinii pneumonia (PCP)

- most common opportunistic infection in AIDs

151
Q

What is a common complication of PCP?

A

pneumothorax

152
Q

What investigations are carried our for PCP?

A
  1. CXR: bilateral interstitial pulmonary infiltrates but can present with other x-ray findings e.g. lobar consolidation.
  2. Sputum often fails to show PCP
  3. Special test: bronchoalveolar lavage (BAL) - often needed to demonstrate PCP (silver stain shows characteristic cysts)
153
Q

When is PCP prophylaxis indicated?

A

all patients with a CD4 count < 200/mm³

154
Q

What is Tuberculosis?

A
  • Infection caused by Mycobacterium tuberculosis that most commonly affects the lungs
155
Q

What are the types of TB?

A

Primary TB - 1st infection (evidence of symptoms)

Secondary TB - If the host becomes immunocompromised the initial infection may become reactivated

Latent disease - not clinically active, not contagious, can become active

Extra- pulmonary TB - manifest in other organs (brain, CNS)
–> CNS - TB meningitis

156
Q

What are the symptoms of TB?

A
  1. Coughing > 3 weeks
  2. Haemoptysis
  3. Night sweats
  4. Unintended weight loss
157
Q

What are the investigations carried out for TB?

A

1) Chest x-ray
- upper lobe cavitation is the classical finding of reactivated TB
- bilateral hilar lymphadenopathy

2) Sputum smear
- 3 specimens are needed
- rapid and inexpensive test
- stained for the presence of acid-fast bacilli (Ziehl-Neelsen stain)
- -> all mycobacteria will stain positive

3) Sputum culture
- the gold standard investigation
- more sensitive than a sputum smear and nucleic acid amplification tests
- can assess drug sensitivities
- can take 1-3 weeks

4) Nucleic acid amplification tests (NAAT)
- allows rapid diagnosis (within 24-48 hours)
- more sensitive than smear but less sensitive than culture

158
Q

What is the gold standard investigation for TB?

A

Sputum culture

159
Q

What is the management for active TB?

A

Initial phase - first 2 months (RIPE)

  • Rifampicin
  • Isoniazid
  • Pyrazinamide
  • Ethambutol

Continuation phase - next 4 months

  • Rifampicin
  • Isoniazid
160
Q

What are the side effects of the drugs used in TB?

A

Rifampicin = hepatoxicity , orange tears & urine

Isoniazid = hepatoxicity, peripheral neuropathy

Pyrazinamide = gout

Ethambutol = optic neuritis

161
Q

What should all patients with TB be tested for?

A

HIV

162
Q

What is Bronchiectasis?

A

Permanent dilatation of the airways secondary to chronic infection or inflammation.

163
Q

What are the causes of Bronchiectasis?

A
  • post-infective: tuberculosis, measles, pertussis, pneumonia
  • cystic fibrosis
  • bronchial obstruction e.g. lung cancer/foreign body
  • immune deficiency: selective IgA, hypogammaglobulinaemia
    allergic bronchopulmonary aspergillosis (ABPA)
164
Q

What are the symptoms of Bronchiectasis?

A
  1. Persistent production of mucous
  2. Cough >8 weeks
  3. SOB
165
Q

What are the signs for Bronchiectasis?

A
  1. Coarse crackles
  2. Wheeze
  3. Stridor
  4. large airway rhonchi (snore-like)
166
Q

What are the investigations for Bronchiectasis?

A
  1. CXR (1st line)
    - Tramlines
    - honey-combing
  2. High-resolution computered tomography (gold-standard)
    - bronchial wall dilation
  3. Spirometry
  4. Assess for cystic fibrosis
167
Q

What are the most common organisms causing Bronchiectasis?

A
  • Haemophilus influenzae (most common)
  • Pseudomonas aeruginosa
  • Klebsiella spp.
  • Streptococcus pneumoniae
168
Q

What is the management for Bronchiectasis?

A
  1. physical training (e.g. inspiratory muscle training)
  2. postural drainage
  3. antibiotics for exacerbations + long-term rotating antibiotics in severe cases
  4. bronchodilators
  5. immunisations
  6. surgery in selected cases (e.g. Localised disease)
169
Q

What abx are used in bronchiectasis?

A
  • amoxicillin
  • doxycycline
  • clarithomycin
170
Q

What is Cystic Fibrosis?

A
  • An autosomal recessive disorder causing increased viscosity of secretions (e.g. lungs and pancreas)
171
Q

What are the presenting features of Cystic Fibrosis?

A
  • neonatal period : meconium ileus, less commonly prolonged jaundice
  • recurrent chest infections
  • malabsorption: steatorrhoea, failure to thrive
  • other features (10%): liver disease
172
Q

What are some other features associated with Cystic Fibrosis?

A
  • short stature
  • diabetes mellitus
  • delayed puberty
  • rectal prolapse (due to bulky stools)
  • nasal polyps
  • male infertility, female subfertility
173
Q

What test is used for diagnosis of Cystic Fibrosis?

A
  • *Sweat test**
  • patient’s with CF have abnormally high sweat chloride
  • normal value < 40 mEq/l, CF indicated by > 60 mEq/l
174
Q

What is the management of Cystic Fibrosis?

A
  • Involves MDT approach
  1. regular (at least twice daily) chest physiotherapy and postural drainage.
    - Parents are usually taught to do this.
    - Deep breathing exercises are also useful
  2. high calorie diet, including high fat intake*
  3. patients with CF should try to minimise contact with each other to prevent cross infection with Burkholderia cepacia complex and Pseudomonas aeruginosa
  4. vitamin supplementation
  5. pancreatic enzyme supplements taken with meals
  6. lung transplantion
175
Q

What is Pulmonary Hypertension?

A
  • Mean pulmonary arterial pressure > 25 mmHg at rest
176
Q

What are the symptoms of Pulmonary Hypertension?

A
  • Chest pain
  • Exertional SOB
  • Fatigue
  • Syncope
177
Q

What are the signs of Pulmonary Hypertension?

A
  • Large A wave in JVP
  • Peripheral cyanosis
  • Parasternal - right ventricular heave
  • Peripheral oedema
178
Q

What are the special tests carried out in Pulmonary Hypertension?

A
  • Echo : dilated R ventricle with impaired function
  • Cardiac catheterisation : essential for diagnosis
  • CT or MRI : enlargement of pulmonary arteries
179
Q

What is the management of Pulmonary Hypertension?

A
  • Diuretics: control oedema from HF
  • O2: correct hypoxia
  • Anticoagulation : for PAH
180
Q

What are the ECG findings in Pulmonary Hypertension?

A
  • RAD
  • R wave in V1
  • Inverted T wave in right pericardial leads
  • RBB
  • Tall peaked p waves in lead II
181
Q

What does SSRI in 3rd trimester cause?

A
  • Pulmonary HTN in newborn
182
Q

What is Pleural Effusion?

A

Fluid collect between the parietal and visceral pleural surfaces of the thorax

183
Q

What is the aetiology of Pleural Effusion?

A
  • if the normal flow of fluid is disrupted with either too much fluid production or not enough being removed.
184
Q

What are the symptoms of Pleural Effusion?

A
  • SOB
  • Non productive cough
  • Pleuritic chest pain
185
Q

What are the signs of Pleural Effusion?

A
  • Quieter breath sounds
  • Decreased or absent tactile fremitus
  • Dull to percuss
  • Reduced chest expansion
186
Q

How can Pleural Effusion be classified?

A

According to the protein conc:
1. Transudate (< 30 g/L)

  1. Exudate (> 30g/L)
187
Q

What investigation are carried out for Pleural Effusion?

A

Imaging:

  • Posterioranterior (PA) chest x-ray
  • USS: for pleural aspiration
  • Contrast CT : investigate underlying cause

Pleural aspiration :
- fluid sent for pH, protein, LDH, cytology and microbiology

188
Q

What is light’s criteria?

A

Used to distinguish between transudate and exudate

189
Q

What are the pleural findings indication in pleural effusion

A
  1. low glucose: rheumatoid arthritis, tuberculosis
  2. raised amylase: pancreatitis, oesophageal perforation
  3. heavy blood staining: mesothelioma, pulmonary embolism, tuberculosis
190
Q

When is pleural fluid sampling diagnostic?

A
  • Pleural infection : all pt with pleural effusion associated with sepsis or pneumonia
    1. Fluid = purulent or cloudy –> chest tube for drainage
    2. Fluid = clear but pH < 7.2 –> chest tube placed
191
Q

What are the pleural findings in empyema?

A

Turbid effusion with :

  1. pH < 7.2
  2. low glucose
  3. high LDH
192
Q

How do you manage Pleural Effusion?

A
  1. CHF
    - Diuretic : furosemide
  2. Symptomatic large effusion
    - Therapeutic thoracentesis
    - O2
  3. Infective
    - IV abx : amoxicillin + metronidazole
    - Therapeutic thoracentesis
193
Q

What is Pneumothorax?

A
  • when air gain access to & accumulates in the pleural space
194
Q

What are the types of pneumothorax?

A
  1. Primary - occurs without a cause
  2. Traumatic - results of trauma. commonly - stab wound
  3. Tension - large amount of air present within the lung causing the lung to deflate
195
Q

What are the symptoms of pneumothorax?

A

Symptoms onset sudden:

  • SOB
  • Pleuritic chest pain
  • sweating
  • tachypnoea
  • tachycardia
196
Q

What are the signs for pneumothorax?

A
  • Absent breath sounds
  • Trachial deviation
  • Hyperressonance on percussion
197
Q

What are the investigations for pneumothorax

A
  • CXR
  • CT : differentitate between emphysema + pneumothorax
  • Bronchoscopy
198
Q

What is the management of secondary pneumothorax if < 1 cm?

A
  • Admit + give oxygen for 24 hours + review
199
Q

What is the management of Primary Pneumothorax?

A
  1. < 2 cm + no SOB = discharge
  2. Otherwise, aspirate
  3. > 2 cm or SOB = chest drain inserted
200
Q

What is the management of Secondary Pneumothorax?

A
  1. > 50 years old + rim of air is > 2cm +/- SOB = chest drain
  2. 1-2cm = aspiration
    - -> If aspiration fails = chest drain
  3. All patients should be admitted for at least 24 hours
    if the pneumothorax < 1 cm
    –> oxygen + admitting for 24 hours
201
Q

What conservative advice should be given to someone with Pneumothorax on discharge?

A
  • Smoking cessation
  • Cannot travel until 1 week post x-ray/drainage
  • Avoid scuba diving
202
Q

What scoring system is used for suspected obstructive sleep apnoea?

A

Epworth scale

203
Q

What would the finding of TB be on a chest radiograph?

A

Upper zone fibrosis

204
Q

What is pleurisy?

A

Inflammation of the pleura which compromises lubrication and results in pain

205
Q

What are the signs of pleurisy?

A
  • Reduced breath sounds
  • Pleuritic rub
  • Rapid/shallow breathing
206
Q

What are the symptoms of pleurisy?

A
  • Chest pain
  • sharp stabbing pain
  • worse on inspiration

Dependent on cause:

  • cough (productive)
  • systemic symp: fever, rigors
  • SOB /altered breathing
207
Q

When is a diagnosis of pleurisy made?

A
  • When other differentials have been confidently excluded
208
Q

How to investigate pleurisy?

A

Tests done to r/o other causes:

  • bloods : trop, ABG, D-dimer
  • X-Ray: pneumothorax, pleural effusion
  • CT: show the condition of the pleura
209
Q

What is the management of pleurisy?

A
  • if patient is otherwise stable (PMH)

1st line: NSAIDs
2nd line: indomethacin

Treat underlying cause (Abx)

210
Q

What are the 2 types of lungs cancer based on histology?

A
  1. Small Cell Lung cancer (SCLC)

2. Non- Small Cell Lung Cancer (NSCLC)

211
Q

What are the different types of NSCLC?

A
  1. Adenocarcinoma
  2. Squamous
  3. Large cell
  4. alveolar cell carcinoma
  5. bronchial adenoma
212
Q

What are the features of lung cancer?

A
  1. Persistent cough
  2. haemoptysis
  3. dyspnoea
  4. chest pain
  5. Weight loss
  6. hoarseness
213
Q

What the examination findings of lung cancer?

A
  1. Fixed monophonic wheeze
  2. supraclavicular lympadenopathy or persistent cervical lympadenopathy
  3. Clubbing
214
Q

What is the investigation used for definitive diagnosis for lung cancer?

A

Biopsy guided by CT or bronchoscopy

215
Q

What is the first line investigation when suspecting lung cancer?

A

CXR

- can give false negative

216
Q

What is the referral criteria for 2WW pathway for lung cancer?

A
  1. CXR suggest lung cancer

2. > 40 y/o + unexplained haemoptysis

217
Q

What is the criteria to offer urgent CXR to assess lung cancer?

A

> 40 y/o + 2 or more of:

  • cough
  • fatigue
  • SOB
  • Chest pain
  • weight loss
  • appetite loss
  • smoker
218
Q

What are the electrolyte disturbances caused by small cell lung cancer?

A
  1. ADH –> Hyponatraemia

2. Secretes ACTH –> Cushing’s

219
Q

What is the management of SCLC?

A 
Early stage (T1-2a,N0,M0):
--> Surgery

Limited disease:
–> Chemo + radiotherapy

Extensive disease:
–> palliative chemotherapy

220
Q

What are the features of squamous?

A
  • PTH –> hypercalcaemia

- clubbing

221
Q

Which type of lung cancer may secrete beta-hCG?

A

Large cell carcinoma

222
Q

What is the management of NSCLC?

A
  • Surgery

- Curative or palliative radiotherapy

223
Q

What are the common site for metastases from lung cancer?

A
  • Brain
  • Bone
  • Abdo (Liver)
  • Prostate
  • Adrenal
  • Kidneys
224
Q

What investigation is carried out metastatic tumours?

A

PET Scan

225
Q

What is carcinoid tumour?

A

Slow-growing tumour that originate in cells of the diffuse neuroendocrine system

226
Q

What is carcinoid syndrome?

A
  • Usually occurs when metastases are present in the liver + release serotonin into circulation
227
Q

What symptoms does carcinoid tumour cause?

A

Entire body involvement:

  • Flushin
  • diarhhoea
  • bronchospasm
  • hypotension
  • valvular stenosis (right)
228
Q

What are lung nodules?

A

Circular/round structures on CXR/CT <3cm

229
Q

What can cause lung nodules?

A
  • Benign tumours
  • lung infection
  • scars from previous infection
  • cancer
  • Autoimmune disorder
230
Q

Management of lung nodules

A

Refer to specialist

231
Q

What is

Idiopathic pulmonary fibrosis?

A

Chronic lung condition characterised by progressive fibrosis of the interstitium of the lungs.

232
Q

What are the features of Idiopathic pulmonary fibrosis?

A
  1. progressive exertional dyspnoea
  2. bibasal fine end-inspiratory crepitations on auscultation
  3. dry cough
  4. clubbing
233
Q

What investigation is used for diagnosis of Idiopathic pulmonary fibrosis?

A

High - resolution CT scan

234
Q

What is the CXR finding for Idiopathic pulmonary fibrosis?

A

bilateral interstitial shadowing - typically small, irregular, peripheral opacities -

  • ‘ground-glass’
  • later progressing to ‘honeycombing’
235
Q

What is the management of Idiopathic pulmonary fibrosis?

A
  • Pulmonary rehabilitation
  • Supplementary oxygen
  • Eventually lung transplant
236
Q

What is the prognosis of Idiopathic pulmonary fibrosis?

A
  • Poor (3-4 year)
237
Q

What is Pneumoconiosis?

A

Accumulation of dust in the lungs
- and response of the bodily tissue to its presence

AKA - Black lung disease

238
Q

What is the CXR finding for pneumoconiosis?

A
  • Upper zone fibrosis
239
Q

Management of pneumoconiosis

A
  • Manage symptoms of chronic bronchitis
  • Pulmonary rehab
  • corticosteroid therapy
240
Q

What are the symptoms of pneumoconiosis?

A
  • SOBOE

- Cough (black sputum)

241
Q

What are the examination findings for pneumoconiosis?

A
  • Normal chest exam

- crackles OA

242
Q

What is Sarcoidosis?

A

Multisystem disorder of unknown aetiology characterised by non-caseating granulomas
–> Small patches of red and swollen tissues

243
Q

What are the features of Sarcoidosis?

A
  • SOB
  • Dry cough

Acute:

  • eythema nodosum
  • bilateral hilar lymphadenopathy
  • swinging fever
  • polyarthralgia
  • Hypercalcaemia
244
Q

How is Sarcoidosis diagnosed?

A
  • No diagnostic test, largely clinical
245
Q

What is the 1st line management of Sarcoidosis ?

A

Oral glucocorticoid

steroids

FCM Matrix (17 decks)

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