resp

Question 1

COPD: symptoms?

Answer 1

Suspect COPD in a long term smoker presenting with

• chronic shortness of breath,
• cough,
• sputum production,
• wheeze
• dysponea
• chest tightness
• and recurrent respiratory infections, particularly in winter.

Associated with the development of both:

• CHRONIC BRONCHITIS: Cough with sputum for 3 months for 2 or more years
  
  • cyanosed
• EMPHYSEMA: Histologically its enlarged airspaces distal to terminal bronchioles, with destruction of alveolar walls
  difficulty breathing but are well perfused

Question 2

COPD: investigations?

Answer 2

Diagnosis is based onclinical presentation plusspirometry

Spirometry = “obstructive picture

FEV1/FVC ratio <0.7 !!!

residual vol and total lung vol are reduced

Chest X-ray: TO EXCLUDE LUNG CANCER

Question 3

COPD: Mx?

Answer 3

SMOKING CESSATION

2. Pulmonary rehabilitation.
3. SABA/LABA for symptom relief.
4. SHORT-ACTING BRONCHODILATORS: EG BETA-2-AGONISTS
   
   1. EG SALBUTAMOL OR TERBUTALINE

IF NO asthmatic or steroid responsive features - they should have a combinedlong acting beta agonist(LABA)

4. ICS.
   If they haveasthmatic or steroid responsive features
   they should have a combinedlong acting beta agonist
   (LABA ) plus aninhaled corticosteroid(ICS)
5. Lung volume reduction surgery - quite rare.

Question 4

CF: define (inheritance too?)

Answer 4

One of the most commonest lethal autosome RECESSIVE conditions in

• *CAUCASIANS**,
• *mutation in CFTR gene**
• *25% condition and 50% carrier risk**

Question 5

CF: pp?

Answer 5

Failure to excrete Cl- leads to Na+ retention. This then leads to H2O retention.

• CFTR: aka cystic fibrosis transmembrane conductance regulator
  
  • Transport protein on membrane of epithelial cells that acts as a chloride channel and Na+ channel

Commonest mutation is the F508 deletion mutation on chromosome 7 and accounts for 70% of cases THUS CFTR PROTEIN WILL BE MISFOLDED

so bc theres loads of positive Na+ inside the cell now - water won’t be attracted to mucus to thin out - THUS mucus is abnormally thick and builds up and obstructs organs

Question 6

CF: symptoms?

Answer 6

thick mucus
Meconium ileus - bowel obstruction due to thick meconium (earliest
stool) (a medical emergency bc can result in bowel perforation!! → can lead to septic shock!!! → organ failure and death!! wo proper Mx will die of cardioresp complications like pneumonia and bronchiectasis)
- distended and rigid abdomen
- mottled and lethargic
- billious vomiting

Pancreatic Insufficiency
THUS fat isn’t absorbed and → steatorrhoea → poor weight gain and failure to thrive
Weight loss and growth retardation.
Malnutrition due to malabsorption
recurrent pneumonia
- Respiratory failure and cor pulmonale.
- delayed puberty
- sinusitis
- breathlessness
- salty sweat
- Chronic Bacterial Infection and Inflammation
- sometimes mucus can get compacted and can lead to mucus plug → BRONCHIECTASIS → = permanent dilation of bronchi walls s cough w lots of sputum can lead to haemoptysis

• Biological Females able to conceive but often develop secondary amenorrhea
  (absence of menstruation) as disease progresses - irregular ovulation
• Biological Males - infertile due to atrophy of vas deferens and epididymis
• digital clubbing
• nasal polyps

Question 7

CF: investigations?

Answer 7

• Clinical history
• Family history of disease
• One or more of these:
  
  • Sweat test: will show high sodium & chloride concentrations greater
    than 60mmol/L (Cl- will be higher)

Genetic screening for known CF mutations

• Nasal Potential Difference Test - INTRANASAL TEST - TO SEE whether there is a negative transepithelial potential difference
• Meconium Ileus is diagnosed by clinical and xray findings
  
  • air fluid levels
  • dilated bowel loops
  • soap bubble appearance / ground glass appearance
• pulmonary function tests - showing obstructive pattern so → FEV1
  
  • cf exacerbaion if FEV1 is 10-15% decrease
• chest x rays

Question 8

CF: Mx?

Answer 8

Regular chest physiotherapy (postural drainage, forced expiratory
techniques)

• BRONCHODILATORS
  
  • B2 adrenergic agonists (eg ALBUTEROL OR salbutamol) & inhaled corticosteroids (beclometasone) -purely for symptomatic relief
• MUCOLYTICS
  
  • LIKE NEBULIZES n-ACETYLCYSTEINE
  • DORNASE ALPHA - these are to clear airways of mucus
• anti-inflammatory agents
  
  • ibuprofen
  • glucocorticoids
  • antibiotc - azithromycin
• Pancreatic enzyme replacement - ezyme supplements for pancreatic insufficency
• Anti-pseudomonal antibiotic therapy.

Pseudomonal & flu vaccine

Question 9

TB: primary TB pp?

Answer 9

Once inhaled into the lung, alveolar macrophages ingest the bacteria

• MOST asymptomatic
• some have flu-like symptoms

about 3 WKS AFTER INFECTION - cell-mediated immunity kicks in and GRANULOMA forms

→ try to wall of bacteria and bacteria in middle die → THUS = CASEOUS NECROSIS aka ghon focus!!!

→ travels to lymph nodes - ghon focuses in hilar lymph nodes!! = GHON COMPLEX (usually subpleural and lower lobes)

→ tissues that has granuloma in undergoes calcification and fibrosis AKA RANKE COMPLEX
miliary tuberculosis whereby TB spreads to other organs

Bacilli settle in lung apex. Macrophages and lymphocytes mount an effective immune response that encapsulates and contains the organism forever.

Question 10

TB: define latent Tb?

Answer 10

In the majority of people who are infected, the immune system contains the infection and the patient develops cell-mediated immunity memory to the bacteria

This is latent TB

Question 11

TB: symptoms?

on xray what do u see?

Answer 11

Systemic features:
• Weight loss (most predictive of TB)
• Low grade fever
• Anorexia
• Night sweats (most predictive of TB)
• Malaise

Pulmonary TB

• Can be asymptomatic
  • Productive cough with occasional haemoptysis
  • Chest pain
  • Breathlessness
• Associated with on xray!!!:
  • Consolidation on CXR
  • Pleural effusion
  • Pulmonary collapse caused by compression of a lobar bronchus by enlarged nodes

Question 12

TB: Mx?

- Compliance in taking TB medication is critical. Why?

Answer 12

RIPE!!!!!

Rifampicin (6 months).

Isoniazid (6 months).

Pyrazinamide (2 months).

Ethambutol (2 months).

Resistance and relapse may be likely if the patient is non-compliant.

Question 13

• Why does TB cause hypercalcaemia?

Answer 13

Granulomatous diseases -> increased vitamin D production and so increased bone resorption, increased absorption from gut and increased re-absorption from kidney.

This is also seen in sarcoidosis.

Question 14

• A special culture medium is needed to grow TB. What is the medium called?

Answer 14

Lowenstein Jensen Slope.

this medium: 

1. It contains growth factors that promote mycobacterial growth.
2. It contains small amounts of penicillin that prevent pyogenic bacteria growth.

Question 15

Bronchiolitis: define and aetiology?

Answer 15

Bronchiolitis describes inflammation and infection in thebronchioles, the small airways of the lungs.

usually caused by avirus.

Respiratory syncytial virus (RSV) is the most common cause.

Question 16

bronchiolitis: symptoms and abnormal airway signs?

Answer 16

• Coryzal symptoms. These are the typical symptoms of a****viral upper respiratory tract infection: running or snotty nose, sneezing, mucus in throat and watery eyes.
• Signs of respiratory distress

Tachypnoea(fast breathing)

Apnoeasare episodes where the child stops breathing\

Wheezeandcrackleson auscultation

• Wheezingis a whistling sound caused by narrowed airways, typically heard during expiration
• Gruntingis caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure
• Stridoris a high pitched inspiratory noise caused by obstruction of the upper airway, for example incroup

Question 17

Bronchiolitis: Mx?

Answer 17

Mostly supportive
- O2, fluids, ventilatory support

Also palivizumab - is a mca that targets the rSV - respiratory syncytial virus

Question 18

Bronchiectasis: define and aetiology?

Answer 18

Chronic infection of the bronchi and bronchioles leading to permanent
dilatation of these airways

Ectasis =dilation!!!!!

Aetiology =Results from pulmonary CHRONIC inflammation and scarring due to infection,
bronchial obstruction or lung fibrosis (e.g. following radiotherapy)

1. Often post-infective e.g. previous pneumonia, TB or whooping cough infection.
2. Congenital causes e.g. primary ciliary dyskinesia.
3. 50% idiopathic.

Question 19

Bronchiectasis: symptoms?

Answer 19

productive cough with large amounts of discoloured/pussy aka purulent sputum

and dilated, thickened bronchi detected on CT

• Dyspnoea AKA SOB
• foul-smelling mucus
• Finger clubbing especially in cystic fibrosis
• Wheeze
• recurrent chest infections
• Haemoptysis
  Chest pain

Question 20

Bronchiectasis: investigations?

Answer 20

• High resolution CT scan.
• Spirometry - would be obstructive.
• Sputum culture.
• CXR. - dilated bronchi

Question 21

Bronchiectasis: Mx?

Answer 21

. Education.

2. Smoking cessation.
3. Annual influenza and pneumococcal vaccinations.
4. Antibiotics.
5. Anti-inflammatories.
6. Bronchodilators.
7. Improved mucus clearance e.g. physiotherapy.

Question 22

Pleural effusion: define

Answer 22

A pleural effusion is the excessive accumulation of fluid in the pleural space

Question 23

Pleural effusion: pp?

Answer 23

Too much fluid is produced: either due to

• Transudative pleural effusion - transparent i.e. less protein:
  
  • When too much fluid starts to leave the capillaries
  Due to either:
  • increased hydrostatic pa
    
    • Eg due to HF (bc blood backs up into pulmonary vessels and inc pathus forcing fluid out of capillaries into pleural space)
  • Or decreased on oncotic pa
    
    • Due to solutes not being able to move across capillary eg due to cirrhosis and nephrotic syndrome
• Exudative effusion - exudes proteins:
  
  • Due to inflammation of pul capillaries → thus makes them more leaky bc the larger spaces between endothelial cells = → allows fluid, immune cells, large proteins eg lactate dehydrogenase to leak out
  • Due to trauma, malignancy, inflammatory conditions eg lupus and infection eg pneumonia like an abscess

Question 24

Pleural effusion: investigations?

Answer 24

1. Take a good history.
2. Imaging.
3. Thoracentesis - can tell you transudates v exudates.

• decreased breath sounds
• dullness to percussion
• decreased tactile fremitus
• Diagnostic aspiration:
  • Known as thoracentesis or pleural tap • Needle inserted under anaesthesia
  
  • Transudative fluid = clear
  • Exudative fluid = cloudy and full of immune cells and much more proteins
  • Lymphatic fluid = milky and filled w fats

Question 25

Pleural effusion: Mx?

Answer 25

- Depends on the underlying cause - **Exudates** are usually **drained** if symptomatic - **Transudates** are managed by **treatment of underlying cause -** Malignant effusions usually reaccumulate after drainage

Question 26

Pneumothorax: define

Answer 26

- **Means air in the pleural space** - Leads to **partial or complete collapse of the lung** - Can occur **spontaneously OR secondary to** other things like trauma, medical interventions (iatrogenic), lung pathology like infection, asthma, COPD

Question 27

pneumothorax: epidemiology?

Answer 27

Spontaneous pneumothorax is most common in young males - Generally a pneumothorax is MUCH MORE COMMON in MALES - Often patients **are tall and thin** - **sudden shortness of breath** - Maybe whilst **playing sports** - W **pleuritic chest pain** Both lungs are affected with equal frequency i.e. can occur in any lung right or left equally

Question 28

Tension pneumothorax: define

Answer 28

When you have a **one-way valve** which LETS AIR IN but NOT AIR out SO during inspiration - air is drawn into pleural space and during expiration - air is **trapped in pleural space** This means → pneumothorax gets **PROGRESSIVELY LARGER W EACH BREATH** → THUS **increased pa in thorax and pushes mediastinum across** → THUS **kinking big vessels in mediastinum** and **causing CARDIORESP arrest** - A pleural tear creates a 1-way valve through which air passes in inspiration -> increased intra-pleural pressure -> respiratory distress, shock and cardiac rest.

Question 29

Tension pneumothorax: signs?

Answer 29

- **tracheal deviation away from affected side** - Reduced air entry **** - Increased resonance - Haemodynamic instability - **tachycardia**, **hypotension** - **tachypnoea (rapid breathing),** - Low O2

Question 30

Pneumothorax: investigations?

Answer 30

- **CXR:** - DO NOT REQUEST IN TENSION PNEUMOTHORAX - WASTES TIME!!!! - **Erect** chest X-ray! - standing upright w lungs fully expanded - Look for **area devoid of lung markings**, peripheral to the edge of the collapsed lung - Measure the size of pneumothorax - **CT Thorax** - Can see small pneumothoraxes - Arterial Blood Gases (ABG): • In dyspnoeic patients check for hypoxia

Question 31

Pneumothorax and tension pneumothorax: : Mx?

Answer 31

- **NO SOB + <2CM** - **NO TREATMENT and follow up CXR** bc usually spontaneously resolves - **SOB and/or >2cm** - **aspiration** But if aspiration fails twice- have to do a **chest drain** to properly drain pneumothorax - **Pneumothorax due to trauma, haemothorax or mechanical ventilation** - requires a **chest drain** For TENSION PNEUMOTHORAX: immediate needle decompression/aspiration - INSERT a **large bore cannula into the 2nd intercostal space in the mid-clavicular line**- Creates a way for air to get out - Needle aspiration to remove excess air - then chest drain inserted into triangle of safety (bc least likely to damage local structures) - 5th intercostal line, mid-axillary line, anterior axillary line - needle is inserted just above rib Then chest X-ray to check positioning DO NOT WAIT FOR INVESTIGATIONS - do **needle aspiration then chest drain!!!!!** - NEEDLE ASPIRATION FIRST

Question 32

Whooping cough: define

Answer 32

Contagious infection caused by bacteria bordatella pertussis Caused by Bordatella pertussis, a GRAM-NEGATIVE COCCOBACILLUS (ROD)

Question 33

Whooping cough: symptoms?

Answer 33

- **violent coughing spells or paroxysms** - The swollen airways make **whooping noise** - **Incubation period is 7-10 days** - Bordatella pertussis is in resp tract and hasn’t multiplied enough to create damage ``` Catarrhal phase (1-2 weeks): • Patient highly infectious/contagious Rhinorhoea (nasal cavity congested with significant amount of mucus) - **cough** - **Low grade fever** ``` Paroxysmal phase (1-6 weeks): • Begins 1 week later from catarrhal phase • Coughing spasms - machine gun bursts - uninterrupted fits of coughing - whopping noise vomiting • Cough for more than 14 days - collapsed lung, broken ribs, petechiae

Question 34

Whooping cough: investigations?

Answer 34

Best to diagnose during catarrhal phase so ab can kill bacteria and reduce damage - But **culture of a nasopharyngeal swab** remains necessary for definitive diagnosis - I**dentifying DNA of bacteria by PCR tests** are rapid and highly sensitive - **Direct fluorescent antibody - detects bordatella pertussis antigens** - **pertussis serology** - looking for antibody response ****

Question 35

Whooping cough: Mx?

Answer 35

- Antimicrobials such as **macrolides** e.g. **AZITHROMYCIN OR CLARITHROMYCIN** will eliminate carriage of bacteria and reduce symptoms in catarrhal stage and early paroxysmal stage In the paroxysmal stage, antibiotics have little role to play in altering the course of the illness - PREVENT transmission to other individuals by isolating infected individuals and giving AB prophylaxis to hosuehold contacts - **Vaccination** - Acellular pertussis as part of the **dTap vaccine (diptheria, tetanus and acellular pertussis**) at 2,3,4 months and 3-4 years -

Question 36

aspiration pneumonia: define?

Answer 36

develops as a result of aspiration, meaning after inhaling foreign material such as food

Question 37

CAP and HAP pneumonia: aetiology?

Answer 37

Organism indicated in CAP: - **Streptococcus pneumoniae (most common)!!!** - Gram positive cocci chain. Alpha haemolytic and optochin sensitive. - **Haemophilus influenzae** - Atypical: - **Mycoplasma pneumoniae** - **Chlamydophila pneumoniae** - Organisms indicated in HAP: - GRAM-NEGATIVE BACTERIA: - Pseudomonas aeruginosa - E.coli - Klebsiella pneumoniae - **Staphylococcus Aureus including MRSA**

Question 38

Pneumonia: symptoms?

Answer 38

productive cough (pus or bloody sputum) so or haemoptysis - **Fever** +/- raised respiratory rate & heart rate and low BP - **sweats** - Rigors - **Malaise** - **Delirium (acute confusion associated with infection)** - **Sepsis** - **Myalgia, headache, arthralgia suggests atypical pneumonia.** Dyspnoea and breathlessness Pleuritic chest pain - (sharp chest pain worse on inspiration)

Question 39

Pneumonia: characteristic chest signs?

Answer 39

- ***Bronchial breath sounds***. These are harsh breath sounds equally loud on inspiration and expiration. These are caused by **consolidation of the lung tissue around the airway.!!!!** - ***Focal coarse crackles***. These are air passing through sputum in the airways similar to using a straw to blow in to a drink. - ***Dullness to percussion*** due to lung tissue collapse and/or consolidation. - Pleural effusion - stony dull percussion - Crackles and wheeze. - Abnormal vital signs.

Question 40

Pneumonia: investigations?

Answer 40

CXR: - look for air bronchogram in consolidated area. - **dullness to percussion = consolidation** - **tactile vocal fremitus** - when u can feel more vibrations from person’s back on repeating certain phrases - **late inspiratory crackles** - **bronchial breath sounds** - **ESR & CRP are usually significantly elevated** - Biochemistry: • **For urea, electrolytes and LFTs** Blood tests: • FBC - **Microbiological tests: • Sputum culture and antibiotic sensitivities +/- Gram Stain • Blood culture (low sensitivity) • Serology - for viruses and atypical organisms** - **CURB-65** is used **to assess severity of CAP!!!!**: **CRB-65 out of hospital and CURB-65 in hospital** - One point each for: - **C**onfusion - **U**rea (greater than 7mmol/L) - **R**espiratory rate greater than 30/min - **BP** less than 90mmHg systolic and/or 60mmHg diastolic - **Age greater than 65**

Question 41

Pneumonia: Mx?

Answer 41

Maintain O2 stats between 94-98% - First dose of **antibiotics** should be administered within 4 hours of presentation in hospital and treatment should not be delayed whilst investigations are awaited - **Mild CAP**: **5 day cours**e of **oral** antibiotics **(amoxicillin or macrolide)!!!!!** - **Moderate to severe CAP**: **7-10 day course** of **dual antibiotics (amoxicillin and macrolide)!!!** - **severe pneumonia (a CURB65 score of >3**) = **IV co-amoxiclav and clarithromyocin.** - **severe pneumonia (a CURB65 score of >4)** be treated = in hospital, consider admission to critical care.

Question 42

Pneumonia: prevention?

Answer 42

- **Polysaccharide Pneumococcal Vaccine** (protects against 23 serotypes) - **Influenza vaccine to those who are older than 65 years, immunocompromised or with medical co-morbidities** - **Smoking cessation**

Question 43

asthma: 2 types?

Answer 43

- **Allergic/eosinophilic asthma (70%):* → due to Allergens (e.g**. fungal allergens and pets etc**.) & atopy there’s 2 types within this: - Extrinsic (atopic): - Occurs most frequently in atopic individuals - Childhood asthma often accompanied by eczema - Intrinsic - allergens not relevant - Often starts in middle-aged - **Non-allergic/non-eosinophilic (30%):** - Exercise, cold air & stress - Smoking & non smoking associated - Obesity associated

Question 44

asthma: 3 cracteristics?

Answer 44

**Three characteristics:** - **Airflow limitation** - usually *reversible spontaneously or with treatment* - **Airway hyper-responsiveness** - **Bronchial inflammation** with T lymphocytes, mast cells, eosinophils with associated plasma exudation, oedema, smooth muscle hypertrophy, mucus plugging and epithelial damage

Question 45

asthma: smptoms?

Answer 45

- **Intermittent dysponea (difficulty breathing)** - **Wheeze** or **high pitched whistline** - **chest tightness** - **Cough (especially nocturnal) - frequent symptom in children** - **Sputum -** may be **curschmann spirals mucus plugs or casts from small bronchi** OR **charct-leyden crystals - small needle=shaped from breakdown of crystals** - **Diurnal variation - often worse in the morning** - Symptoms worse at night - Episodic shortness of breath

Question 46

asthma: investigations?

Answer 46

- **RCP3** questions: used to assess the severity of asthma. - **Recent nocturnal waking?** - **Usual asthma symptoms in day?** - **Interference with ADLs? (activity of daily living) -** May also want to ask about whether the patient has used any rescue medications. - Lung function tests: - **Peak expiratory flow rate (PEFR)** - measurement on waking, prior to taking a bronchodilator and before bed, after a bronchodilator - **variable** Spirometry - useful in assessing reversibility - should show an obstructive pattern; FEV1 < 80%, FEV1/FVC < 0.7, PEFR - variable Test for atopy - RAST, Skin prick tests to help identify allergic trigger factors - Criteria for diagnosis * *1. RR > 25.** * *2. HR > 110.** * *3. PEFR 35-50% predicted.** * *4. Unable to complete a sentence in one breath.**

Question 47

asthma: mx?

Answer 47

* SABA mild * SABA + ICS * SABA + LABA + ICS * SABA + LABA + ICS + 4th drug e.g. anti-IgE monoclonal etc. severe - **Bronchodilators**: so - **Beta2-agonists:** so SABAs like salbutamol or LABA Salmeterol Formoterol (full agonist) - Anti-inflammatory steroids so eg - **• Inhaled corticosteroids (ICS):!!!!!!!!** eg • Prednisolone • Beclomatasone • Budesonide acute severe asthma = Nebulised salbutamol with oxygen. IV corticosteorids and abx if evidence of infectio

Question 48

sarcoidosis: symptoms?

Answer 48

**OFGREN’S SYNDROME:** - **ERYTHEMA NODOSUM** - **bilateral hilar lymphadenopathy** - **polyarthralgia** - joint pain in multiple joints Typically presents with **bilateral hilar lymphadenopathy, pulmonary infiltration and skin or eye lesions** cute sarcoidosis commonly presents with erythema nodusum (red lumps form on the shins and less commonly thighs and forearms) Constitutional symptoms: • Fever • Weight loss • Fatigue • Dry cough • Progressive dyspnoea/SOB wheeze Other symptoms: • Lymphadenopathy also MEDIASTINAL lymphadenopathy (abnormally large lymph nodes in mediastinum) → • Hepatomegaly and/or liver nodules and/or liver cirrhosis and/or cholestasis • Deranged LFTs • Splenomegaly • Conjunctivitis • Glaucoma • Anterior uveitis (inflammation of the middle eye)!!!!!!!!!!!!!!! Bell’s palsy - **pulmonary fibrosis** - **pul nodules** - **Lupus pernio - blueish-red/purple nodules and plaques over nose, cheek and ears** **• Renal stones** • Cardiac arrhthmias • **Heart block or BBB**

Question 49

sarcoidosis: investigations? gs?

Answer 49

- **Tissue biopsy OF SKIN : GOLD STANDARD • DIAGNOSITIC** • Shows NON-CASEATING GRANULOMATA - **Bronchoscopy** OF mediastinal lymph nodes - histology will show ***non-caseating granulomas w epitheliod cells)*** - **CXR**: - Used for staging: - Stage 0 - normal - Stage 1 - Bilatera**l hilar lymphadenopathy (**BHL) - **high res CT - pul nodules** - **MRI - cns involvement* * - PET scan - active areas of inflammation ``` - **Blood tests:** • Raised ESR • Lymphopenia • Raised LFT **• Raised Ca2+** • Raised immunoglobulins • **Serum ACE (angiotensin converting enzyme)** • 24 hour urinary calcium if blood serum normal - **soluble IL-2 receptors** - **raised CRP** - **raised immunoglobulins** ```

Question 50

sarcoidosis: mx?

Answer 50

1. no treatment for no/mild symptoms 2. oral steroids (6-24mth course) - **Prednisolone** orally then gradually reduce dose • In severe illness give IV **methylprednisolone** 1. bisphosphonates to protect bones whilst they’re on steroids 3. immunosuppressants - **methotrexate or azathioprine** in v severe lung disease = → **lung transplant** - **Treat extra-organ complications**

Question 51

pul htn: define

Answer 51

**increased blood pa in pul circulation** - Normal mean pulmonary artery pressure ***(mPAP) is 14 +/- 3 mmHg*** with an upper limit of normal of 20mmHg - Pulmonary hypertension is **defined as an mPAP of above 25mmHg** as measured at **right heart catheterisation** and secondary right ventricular failure - The *lung circulation offers a low resistance to flow compared to the systemic circulation* (about 90mmHg)

Question 52

pul htn:

Answer 52

1. Hereditary. 2. Idiopathic. 3. Drug use. 4. HIV infection. 5. Pulmonary hypertension secondary to left heart disease (valvular, systolic/diastolic dysfunction most commonly develops as a result of **LEFT HD** **chronic lung disease** → typicall causes hypoxic vasoconstriction - when an area in lung is diseased and unable to deliver O2 to blood chronic thromboembolic pul hypertension

Question 53

pul htn: symptoms?

Answer 53

Initial symptoms: **1. Dyspnoea on exertion.** 2. Lethargy. 3. Fatigue. 4. Syncope. Symptoms as RV failure develops: 1. **Pulmonary oedema.** **2. Abdominal pain.** - **Exertional dyspnoea,** lethargy and fatigue are the initial features due to an inability to increase cardiac output with exercise - if LHS HF = **orthopnoea** - shortness of breath when lying flat

Question 54

pul htn: ix?

Answer 54

- **auscultation - Loud pulmonary secondary sound.** - **Right parasternal heave.** - **CXR: • Enlarged proximal pulmonary arteries which taper distally** • Enlarged heart • May also reveal cause of pulmonary hypertension e.g. emphysema or calcified mitral valve - **ECG: • Right ventricular hypertrophy and P pulmonale (tall & peaked P wave** in) - **ECHO cardiogram:** • **Right ventricular dilatation and/or hypertrophy** • Can show cause of pulmonary hypertension e.g. intra-cardiac shunt - **Spirometry** - *In advanced disease there are signs of RHF, elevated JVP, hepatomegaly and pleural effusion etc.* - LFTs to detect portal hypertension - Autoimmune screening

Question 55

pul htn: mx?

Answer 55

- **Treat underlying cause** - is cardiogenic in nature → meds to boost heart’s performance or decrease BP - if pul arterial htn → **Oral endothelin receptor antagonist e.g. bosenten** OR prostacyclins - **Oxygen** - Warfarin - due to intrapulmonary thrombosis - **Diuretics for oedema** - **Oral calcium channel blockers as pulmonary vasodilator**