Resp Flashcards
Causes of COPD
CIGARETTE SMOKING!
Chronic exposure to pollutants
Alpha-1-antitrypsin deficiency
Types of COPD
Chronic bronchitis and Emphysema
How do you define chronic bronchitis?
Cough with sputum for 3 or more months for 2 or more years
State a characteristic of parapneumonic effusion
Exudative (> 35 g/L protein)
RF COPD
SMOKING
Recurrent lung infections
Environmental tobacco smoke
Genetics
Age
Socio-economic status
Occupational dust and chemical inhalation
Describe the MRC Dyspnoea Scale
1 - Not troubled by dyspnoea unless vigorous exertion
2 - Dyspnoea when walking up incline
3 - Walks slower than other people bc of dyspnoea or stops for breath at own pace
4 - Stops for breath after 100m after few mins
5 - Too breathless to leave the house, or on dressing
Pink puffer signs/symptoms
Weight loss
Barrel-chested
Thin (low BMI)
Emphysematous
Pursed lips
Normal PaO2
Blue bloater sign/symptoms
Cough w/ phlegm
Cyanosis
Overweight
Low PaO2
Ix COPD
- FeNO (Fraction expired nitrous oxide)
is raised non-specific in lung damage - Spirometry
FEV1:FVC < 0.7 = obstruction - Bronchodilator reversibility test
LESS than 12% increase in FEV1 = irreversible ∴ COPD, not asthma
Key presentation of COPD
Productive cough with white or clear sputum, wheeze and breathlessness
Following years of smoker’s cough!!
Tx COPD
STOP SMOKING!!!!
SABA - short-acting beta-2-agonist e.g. salbutamol, terbutaline
LABA - long-acting beta-2-agonist e.g. salmeterol, formoterol
SAMA - short-acting musarinic-antagonist e.g. ipratropium
LAMA - long-acting muscarinic-antagonist e.g. tiotropium bromide
ICS e.g. beclomethasone
- SABA
- SABA + LABA + LAMA
- SABA + LABA + LAMA + ICS
When should LTOT be given?
NON-SMOKERS!
Chronic readings of < 88% O2 sats
PaO2 < 7.3 kPa
OR PaO2 between 7.3 - 8kPA AND have at least one of following:
- 2° polycythaemia
- Peripheral oedema
- Pulmonary oedema
Describe how LTOT should be given
> 15 hrs/day
What surgery can be done for Px with COPD?
When is this most effective?
Lung volume reduction surgery
In Px with upper lobe emphysema and low exercise capacity
What treatment should you avoid in COPD Px?
Chronic treatment with systemic corticosteroids
bc the benefit to risk ratio is too low
What prophylaxis treatments are offered for COPD Px? Why?
Influenza and pneumococcal vaccines
Bc exacerbations caused by recurrent resp diseases
Stages of COPD
FEV1 % - compared to predicted value
STAGE 1 - ≥ 80% (mild)
STAGE 2 - 50 - 79% (moderate)
STAGE 3 - 30 - 49% (severe)
STAGE 4 - < 30% (v severe)
What might an XR show for a COPD patient?
*Low, flattened diaphragm
Long narrow heart shadow
↓ Peripheral lung markings
Bullae
*HYPER-INFLATED LUNGS
DDx COPD
Asthma
Congestive heart failure
Bronchiectasis
Pneumoconiosis
Asbestosis
What are the most common causes of COPD exacerbations?
Viral upper respiratory tract infections
Infections of tracheobronchial tree
Ix COPD exacerbations
ABG
Chest radiographs
ECG
Bloods - WBC count
Tx COPD exacerbations
O2 - target = 88 - 92% !!
Bronchodilators - SABA and/or SAMA
Antibiotics
potentially Non-Invasive ventilation
When should antibiotics be given for COPD exacerbations?
3 cardinal signs :
1. ↑ Dyspnoea
2. ↑ Sputum vol
3. ↑ Sputum purulence
Why is the O2 target sat lower for COPD patients?
Bc of low respiratory drive
∴ can cause hypercapnia is O2 target sat is normal (94-98%)
What are some indication for hospital admissions in COPD patients?
Significant increase in symptom intensity
Severe COPD
Onset of new physical signs
No response to treatment
Serious comorbidities
Freq exacerbations
Elderly patients
Not sufficient home support
COPD is characterised by ?
Neutrophilic inflammation
Asthma is characterised by?
Eosinophilic inflammation
State some microscopic and macroscopic differences between asthma and COPD
Asthma -
Smooth muscle hypertrophy
Basement membrane thickening
Little fibrosis and alveolar disruption
COPD -
Little smooth muscle hypertrophy and basement membrane thickening
Lots of fibrosis and alveolar disruption
Types of asthma
Allergic / Eosinophilic (70%)
Allergens & atophy
Non-allergic / Non-Eosinophilic (30%)
Exercise, cold air, stress, obesity
What age does asthma usually present itself?
Starts in childhood, 3-5 years
Peak prevalence is 5-15 years
Which countries have a higher prevalence of Asthma?
New Zealand, UK, Australia
(HICs)
Name some precipitating factors of Asthma
Occupational
Cold air/water
Exercise
Pollution/irritant dust
Emotion
Drugs - NSAIDs, aspirin
Which hypersensitivity reaction is Asthma?
TYPE 1
Pathophysiology of Asthma
Overexpression of TH2 cells in airway stimulates ↑ IgE production (∴ T1 hypersensitivity)
AND eosinophilia (∴ release of toxic proteins e.g. maltose binding protein)
∴ Leads to chronic remodelling and mucus hypersecretion
Key presentation of Asthma
Cough, Dyspnoea, tight chest
DIURNAL VARIATION
Bilateral wheeze on auscultation
Describe the differences between brittle disease type 1 and 2
TYPE 1 : severe, bad all the time
TYPE 2 : sudden dips - sometimes ok, sometimes not
Associated symptoms of Asthma!
Atopic triad : Asthma, Hayfever, Eczema
Samter’s tried : Asthma, Aspirin allergy, Nasal Polyps
Ix Asthma
Same as COPD
Multiple peak flow measurement required!!
How are mast cells involved in asthma?
When IgE binds to mast cell receptor, mast cell responds to allergen binding to IgE
∴ releases chemicals
What chemicals do mast cells release when allergens bind to IgE (which in turn is bound to mast cells?)
Histamine
Tryptase
Prostaglandin 2
Cysteine leukotrienes
Cytokines - TNF-a, IL3, IL4, IL5
Describe the microscopy of the mucus of an Asthma patient
Curshmann spirals
Charcot-Leydig crystals
Describe the stages of an Asthma attack
Mild / moderate -
*PEFR > 50%
RR < 25
Pulse < 110
Normal speech
Severe
*PEFR 33-50%
RR >/= 25
Pulse >/= 110
Inability to complete sentences
Life-threatening
*PEFR < 33%
SaO2 < 92% or PaO2 < 8kPa
Normal PaCO2 (4.6-6 kPa)
Altered conscious levels, exhaustion, arrhythmias, hypotension, silent chest!!, cyanosis, poor effort
Near fatal
↑ PaCO2 and/or req ventilation with raised airway pressures
Tx Asthma
- SABA
- SABA + ICS
————————— check their technique!! - SABA + ICS + LTRA
- SABA + ICS + LABA +/- LTRA
- ↑ ICS dose
- Maybe another drug e.g. omalizumab anti-IgE antibody
Tx for acute asthma attack
O SHIT ME
Oxygen
SABA
Hydrocortisone (ICS)
Ipratropium bromide
Theophylline
MgSO4
Escalate care
Draw the graph of different types of lung cancer
do it
What questions do you ask to take the history of a Px you suspect has asthma?
*RCP 3 Qs -
1. Recent nocturnal waking?
2. Asthma symptoms in day?
3. Interference w/ day to day activities?
Where are the majority of TB cases?
Africa and Asia (India, China)
What’s the cause of death for most people with HIV?
Tuberculosis
Name the 4 main causes of TB
*Mycobacterium tuberculosis
Mycobacterium bovis
Mycobacterium africanum
Mycobacterium microti
Describe the mycobacteral species that cause TB
Aerobic, non-motile, non-sporing slightly curved rods/bacilli
Thick waxy capsule
Acid fast bacilli go red/pink with Ziehl-Neelsen
How is cystic fibrosis inherited?
Autosomal recessive
Cause of Cystic fibrosis
Mutation of chromosome 7 - codes for CFTR protein
RF Cystic fibrosis
Caucasian !
FHx
Presentation of Cystic fibrosis
Resp - recurrent infections, bronchiectasis
Neonates - jaundice, failure to thrive, meconium ileus
GI - Bowel obstruction, steatorrhoea
Other - male infertility, DM
Other than respiratory problems, what other systemic problem do Px with cystic fibrosis have?
Pancreatic insufficiency
What is a common ECG finding for pulmonary embolism?
Sinus tachycardia
Why does PE cause tachycardia?
Body attempts to increase cardiac output to compensate for hypoxia
Key presentation of cystic fibrosis
Cough
Thick mucus production
Pancreatic insufficiency - poor weight gain, steatorrhoea
SALTY SWEAT
Other signs/symptoms of cystic fibrosis
Fever
Neonates - meconium ileus
Recurrent infections
Clubbing
Male infertility - absent vas deferens and epidiymis
Nasal polyps
Wheeze
Haemoptysis
Increased freq of gallstones
Ix Cystic fibrosis
Lung function test
Faecal elastase test
GS : Sweat test - Na+ and Cl- > 60 mmol/L
Screening test of Cystic fibrosis
Genetic newborn screen - used in countries w ↑ prevalence or CF family history
Measures immunoreactive trypsinogen (IRT), neonatal heel prick
Why does pancreatic insufficiency cause steatorrhoea?
Enzymes are not released to digest fat
∴ Fatty stools
Tx Cystic fibrosis
MDT approach!!
*Nutrition & healthy weight gain (fat soluble vitamins - DAKE, diet = high calorie, high fat)
*Regular chest physio, postural drainage
Inhalers (ICS, SABA)
Prophylactic Abx
*Pancreatic supplementation
What Abx is commonly used against S. Aureus?
Flucoxacillin
What Abx is commonly used against H. Influenzae?
Amoxicillin
What Abx is commonly used against Psuedomonas aeruginosa?
Ciprofloxacin
What are good prognostic markers for CF?
Lung function (FEV1) and BMI
What Abx is commonly used against MRSA?
Rifampicin and Fucidin
When would a lung transplant for CF be used?
Px sick but not too sick i.e. FEV1 close to 30%
Px on max therapy and compliant
HLA compatibility
Complications of CF
Bronchiectasis, infections
Brief pathophysiology of CF
Normally, CFTR protein allows Cl- to be transported across epithelial into secretions.
However, if damaged this doesn’t happen.
∴ water potential ↑
∴ water doesn’t move into secretions -> becomes thicker
∴ mucus isn’t wafted up ∴ bacteria colonises lungs
What is Sarcoidosis?
Interstitial lung disease, disease of alveolar/capillary interface
Immune response occurs repeatedly without a pathogen triggering it, cause not entirely known
Epidemiology of Sarcoidosis
20 - 40 years
F > M
African-Caribbeans more affected
RF Sarcoidosis
African American
FHx
Prior infection with M. tuberculosis
Key presentation of Sarcoidosis
Fever, weight loss, dry cough
Lupus pernio - purple rash on cheeks and shins, seen in chronic
Bilateral hilar lymphadenopathy
Can be asymptomatic & found incidentally on CXR
What organs do sarcoidosis affect?
Can affect any organs but mostly lungs
State some common extrapulmonary manifestations of Sarcoidosis
Ant. uveitis, erythema nodosa, skin papule, peripheral lymphadenopathy, hepatosplenomegaly
State some less common extrapulmonary manifestations of Sarcoidosis
Bone, heart (arrhythmias), CNS (Bell’s palsy), kidneys
Ix Sarcoidosis
Bloods - ↑ ACE, ↑ Ca2+
CXR - bilateral hilar lymphadenopathy (used for staging) + pulmonary infiltrates
GS : Biopsy - shows NON caseating granulomas
Other :
ECG - might show arrhythmias or BBB
Bronchoalveolar lavage - ↑ lymphocytes in active disease, ↑ neutrophils if pulmonary fibrosis
DDx Sarcoidosis
RA
Lymphoma
Metastatic malignancy
TB
Lung cancer
SLE
Idiopathic pulmonary fibrosis
Multiple myeloma
Tx Sarcoidosis
In early stages, can resolve spontaneously
If persistent - steroids (prednisolone)
Transplant if extreme
CXR Staging of Sarcoidosis
STAGE 0 - no changes
STAGE I - bilateral hilar lymphadenopathy
STAGE II - ^BHL and diffuse interstitial disease
STAGE III - interstitial disease ONLY (reticulonodular pattern)
STAGE IV - pulmonary fibrosis (honeycombing)
Which Sarcoidosis patients do NOT require Tx?
Symptomatic patients, Stage 1
Asymptomatic patients, Stage 2 or 3
When is the mean onset of Idiopathic pulmonary fibrosis?
60s
Presentation is very uncommon < 50 years
RF Idiopathic pulmonary fibrosis
Male
60+
Cigarette smoking
Infectious agents (Hep C, EBV, CMV)
Drugs - methotrexate, imipramine
GORD
Genetic predisposition
Occupational exposure to metal and wood
Pathophysiology of Idiopathic pulmonary fibrosis
Tissue becomes damaged by environment
Wound healing mechanism becomes uncontrolled
∴ overproduction of fibroblasts & deposition of extracellular matrix in interstitium w/ little inflammation
∴ loss of elasticity
∴ ↓ Effective gas exchange
∴ Leads to TYPE 1 RESP FAILURE
Key presentation of Idiopathic pulmonary fibrosis
Exertional dyspnoea, dry cough, bibasal crackles
Other signs/symptoms of Idiopathic pulmonary fibrosis
Weight loss
Arthralgia
Cyanosis
Clubbing
DDx Idiopathic pulmonary fibrosis
COPD
Asthma
Bronchiectasis
CHD
Lung cancer
Hypersensitivity pneumonitis
Asbestosis
Ix Idiopathic pulmonary fibrosis
Bloods :
ABG - ↓ PaO, if severe ↑ CaO2
↑ CRP, ↑ Ig
(Can exclude autoimmune rheumatic diseases by checking for ANA and RhF)
Spirometry function test - shows restrictive pattern! (FEV1:FVC ratio > 0.7 but FVC low! < 75%)
CXR small vol lungs w. ↑ reticular shadowing at base but can be normal in early stages
GS : HIGH RES CT
GROUND GLASS appearance of lungs
What other CT findings are there for Idiopathic pulmonary fibrosis? (Other than ground glass appearance)
Basal distribution
Sub-pleural reticulation
Traction bronchiectasis
Honey combing - small, cystic airspaces w. irregularly thickened walls, made of fibrous tissue
What other Ix can you do for Idiopathic pulmonary fibrosis?
Lung biopsy
Tx Idiopathic pulmonary fibrosis
Supportive care - O2, palliative care i.e. opiates
Non-pharm - stop smoking, physio, up to date vaccines
Pharm - Antifibrotic agent e.g. Pirfenidone
Nintedanib
Treat GORD and cough
Lung transplant as last resort!
Do NOT give high dose steroids
Prognosis Idiopathic pulmonary fibrosis
Median survival= 2-5years
What is Idiopathic pulmonary fibrosis also known as?
Cryptogenic organising pneumonia
Causes of Bronchiectasis
Bronchial obstruction
e.g. foreign body, tumour, thick mucus (CF)
Infection
e.g. Pseudomonas aeruginosa, TB, measles, pneumonia
Congenital
e.g. Ciliary dyskinesia (Kartagener’s syndrome, immotile cilia)
Key presentation of Bronchiectasis
Chronic cough with large amounts of green foul-smelling sputum
Other signs/symptoms of Bronchiectasis
Wheeze
Intermittent haemoptysis
Clubbing
Crackles over affected areas (esp base of lungs)
Recurrent chest infections
Dyspnoea
Chest pain
Ix Bronchiectasis
Lung function test - shows obstructive pattern (FEV1 : FVC < 0.7)
CXR - kerley B lines, SIGNET RING SIGN
Sputum culture
–
GS : HIGH RES CT - thickened, dilated bronchi w/ cysts
airways larger than associated blood vessel
GS Ix Bronchiectasis
HIGH RES CT - thickened, dilated bronchi w/ cysts
airways larger than associated blood vessel
Epidemiology Bronchiectasis
F > M
May develop after lung infections
Pathological end point of many diseases
Presents at any age but incidence ↑ with age
What are some major pathogens in Bronchiectasis?
Haemophilus influenza
Strep. pneumoniae
Staph. aureus
P. aeruginosa
Tx Bronchiectasis
Improve mucus clearance - chest physio, postural drainage
Bronchodilators - nebulised SABA
Prophylactic Abx
Anti-inflammatory agents e.g. azithromycin (reduces exacerbation freq)
Describe the postural drainage that can be done to treat Bronchiectasis
Physio tips patient so affected lobes can drain mucus
Done 3x a day for 10-20 mins
Abx for Pseudomonas aeruginosa (exacerbation of Bronchiectasis)
Oral ciprofloxacin
What causes Bronchiectasis exacerbations?
H. influenzae
S. aureus
Abx for H. influenzae (exacerbation of Bronchiectasis)
Oral amoxicillin, co-amoxiclav, doxycycline
If multi-resistant, needs IV cephalosporin
Abx for S. aureus (exacerbation of Bronchiectasis)
Flucloxacillin
How much fluid in pleural space in Pleural effusion to be detected clinically?
500 ml
How much fluid in pleural space in Pleural effusion to be detected via CXR?
300 ml
Pleural effusion transudate causes
When balance of hydrostatic forces results in ↑ fluid in pleural space -
↑ Hydrostatic pressure
e.g. CHF, Constrictive pericarditis
↓ Plasma oncotic pressure
e.g. Nephrotic syndrome, cirrhosis/hepatic failure
Pleural effusion exudate causes
Damage/altered pleura (∴ loss of tissue fluid and protein) -
Trauma
Neoplastic e.g. lung carcinoma, lymphoma, metastases, mesothelioma
Inflammatory e.g. vascular diseases (RA, SLE), PE, infarction, pneumonia, empyema
Pleural effusion lymphatic causes
Damage during surgery
Malignancy
What is the function of the pleura?
Allows movement of lung against chest wall
Clears fluid from pulmonary interstitium
What does pleural fluid contain ?
Proteins - albumin, globulin, fibrinogen
Many mesothelial cells, monocytes, lymphocytes
When are recurrent pleural effusions seen?
In malignant mesothelioma
RF Pleural effusion
Prev lung damage
Asbestos exposure
Describe transudative fluid
LESS PROTEIN
< 30 g/L
∴ Appears clear in thoracentesis
Describe exudative fluid
MORE PROTEIN
< 30 g/L
∴ Appears cloudy in thoracentesis
Key presentation of pleural effusion
Can be asymptomatic
Dyspnoea on exertion, pleuritic chest pain, cough
Other signs/symptoms of Pleural effusion
Tracheal deviation AWAY from effusion IF LARGE
↓ Breathing sounds
↓ Tactile fremitus
Stony dull percussion on affected side
Ipsilateral decrease in expansion
Pleural friction rub
Orthopnea
Ix Pleural effusion
CXR :
Transudate - bilateral
Exudate - unilateral
Costophrenic angle blunt
Thoracentesis or pleural tap
Tx Pleural effusion
Depends on cause
CHF - loop diuretics
Infective - Abx
Malignant - therapeutic thoracentesis
For large effusions - CHEST DRAIN ! 5TH intercostal space
How can you prevent reaccumulation of pleural effusion?
Pleurodesis e.g. tetracycline
causes adhesion of visceral and parietal pleura
Where is thoracentesis done in reference to the rib? Why?
Done just OVER the rib
To avoid the neuromuscular bundle which lies just below the rib
What is a huge contraindication of thrombolysis in the history of a patient?
A haemorrhagic stroke at ANY TIME IN THEIR LIFE
Clinical presentation examples: - Example 1:
* Mrs P. 72 year old
* Previous MI, Type 2 diabetes, CKD, shortness of breath progressively over 2
weeks
* Bilateral reduced air entry
* Bilateral pedal oedema (swelling of foot and ankles)
* ECG - Left Bundle Branch Block (LBBB) - activation of left ventricle delayed
causing it to contract later than the right ventricle
* CXR - Bilateral pleural effusion
- Most likely heart failure! – maybe renal disease thus transudate
- No need to perform thoracentesis – treat with diuretics
Example 2:
* Mr T. 74 year old retired joiner
* 2/12 (2 months) of “nagging back pain”, breathlessness, fatigue and weight
loss (sign of malignancy)
53
KP
All information is taken from lectures and textbooks, there may be mistakes!!
* CXR shows large left sided pleural effusion with mediastinal shift
* Thoracentesis (diagnostic aspiration) - protein 48g/L means an exudate!
- Looks like a malignancy – so do a biopsy now!
- Do this by visually assisted thoracoscopic surgery – medical thoracoscopy
means shorter stay in hospital and just as good
Pneumonia with associated pleural effusion is called what?
Parapneumonic effusion
Describe the 3 forms of parapneumonic effusion
- Simple (non-infected) - resolves spontaneously, not Tx req
- Complicated (infected) - reqs drainage/intra pleural fibrolytics/surgery
- Empyema - reqs drainage/intra pleural fibrolytics/surgery
Types of pneumothorax
Spontaneous
Traumatic
Iatrogenic
Lung pathology
Tension
Tx Pneumonia
CURB score dependent
0-1 = oral amoxicillin, 5 days
(OR macrolide if penicillin allergy)
2 = dual therapy - amoxicillin + macrolide (IV or oral), 7 days
3+ = IV co-amoxiclav + macrolide
Ix Pneumonia
FBC - ↑ WBC
Sputum culture
GS : CXR - localised/widespread consolidation, effusion, abscesses, empyema
Air bronchogram
What does rusty sputum indicate?
S. pneumoniae
When might pneumonia present with a rash?
If mycoplasma
In a pneumonia patient with HIV or immunocomp, what bacteria would we assume is the cause?
Pneumocystic jiroveci
Pneumonia : water cooler/air conditioner/SPAIN
What bacteria?
Legionella pneumophilia
If a patient has CAP, most likely causal bacteria?
**Step. Pneumoniae
H. influenzae
If a patient has HAP, most likely causal bacteria?
Gram neg bacteria -
Pseudomonas
E.coli
Klebsiella
Staph. aureus (incl MRSA)
Describe pathophysiology of Pneumothorax
Usually pleural space has negative intrapleural pressure
Breach in pleura causes flow of air into pleural space
Key presentation of Pneumothorax
Dyspnoea, one sided sharp pleuritic pain
Hyperresonant percussion note ipsilaterally
Reduced breathing sounds
Ix Pneumothorax
GS and first line CXR
Absent lung markings
Affected area much darker than normal
Tracheal deviation to opp side
IF SUSPECT TENSION PNEUMOTHORAX, STRAIGHT TO Tx WITHOUT CXR !!!!!!!!!!!!!!
Key presentation of tension pneumothorax
Cardiopulmonary deterioration : Hypotension, Resp disease, Low O2 sats, Tachycardia, Shock
Tx Tension pneumothorax
Large bore cannula into pleural space through 2nd intercostal space in midclav line
Define pulmonary hypertension
Resting mean pulmonary arterial pressure (mPAP) > 25 mmHg
Mild : 25-40
Moderate : 40 - 55
Severe : 55+
Causes of pulmonary HTN
Precapillary - 1º pul HTN, pul amboli
Capillary - COPD, asthma
Post capillary - LV failure
Chronic hypoxaemia - COPD, high altitude
Key presentation of Pul HTN
Exertional dyspnoea + Fatigue FIRST
then RV failure (JVP distention, periph oedema, cannon A waves)
What is a cannon A wave?
Large amplitude waves seen in jugular vein
Ix Pul HTN
GS : RH catheter
measures pressure directly
CXR - RVH
ECG - RA dilation (p = pulmonale, peaked p waves)
Tx Pul HTN
Sildenafil - viagra!
-> Phosphodiesterase 5 inhibitor
HAEMOPTYSIS + HAEMATURIA =
GOODPASTURE’S
Ix Goodpasture’s
Serology - Anti-GBM antibody POS
What’s a side effect of ICS inhalers?
oral thrush
What type of hypersensitivity reaction of Hypersensitivity pneumonitis?
Type III
Ix Hypersensitivity Pneumonitis
Usually diagnosed through Hx and examination
CXR - patchy, nodular infiltrates, fibrosis
Tx Hypersensitivity Pneumonitis
Remove allergen!!
Steroids
How is A1AT-def inherited?
Autosomal recessive
How is CF inherited?
Autosomal recessive
What would you see in a Patient’s CT with COPD with A1AT-deficiency as the cause?
Panacinar emphysema
What would you see on a CT of a patient with Emphysema?
Centriacinar (resp bronchioles inv. ONLY - smokers!!)
Panacinar (A1AT def!)
Where is EMPYEMA seen?
CXR on Pneumonia patient
What is EMPHYSEMA?
Type of COPD
RF Bronchiectasis
Infection
CF
Lung cancer
Males, 40-70 with asbestos exposure decades ago, dyspnoea
What do you immediately suspect?
MESOTHELIOMA
Key Presentation Lung cancer
Constitutional symptoms - TATT, weight loss etc
Lung Sx - dyspnoea, recurrent chest pain, constant cough w haempotysis
also : recurrent laryngeal compression = hoarse voice, bone pain
Ix Lung cancer
1st line - CXR, then CT
pleural thickening +/- effusion
GS : BRONCHOSCOPY and BIOPSY
What might be raised non-specifically in mesothelioma?
Usually associated with ovarian cancer
CA-125
Tx Mesothelioma
Why?
Purely palliative :(
v severe aggressive cancer! v low survival rates
What type of people get SCLC?
ONLY SMOKERS!
Name 3 paraneoplastic syndromes of SCLC
Cushing’s - ACTH
SIADH - ADH
Lambert-Eaton syndrome - dysfunction of ACh at nmj
What % of bronchial carcinomas are SCLC?
15%
Where does SCLC affect?
Central resp system (bronchi)
How does SCLC appear on biopsy?
Small cells w/ minimal cytoplasm
Tx SCLC
If caught early, chemo/radiotherapy
Usually palliative
What % does Squamous cell carcinoma account for bronchial carcinoma?
30-35%
Where does squamous cell carcinoma arise from?
Lung epithelium
Squamous cell cancer is the most common type (40% of all lung cancers). Smokers!
Small cell lung cancer = 20-30%. Arises from endocrine cells and in rare cases secretes
ACTH.
Large cell lung cancer = 25% of cases- poorly differentiated.
Adenocarcinoma = most common lung cancer IN NON-SMOKERS.
Bronchial cancer is very rare, starts in the mucous glands and ducts of bronchi or trachea.
peak
What does squamous cell carcinoma appear as on biopsy?
Histologically resembles squamous epithelium
Who does Squamous cell carcinoma mainly affect?
Smokers
Paraneoplastic syndrome of Squamous cell carcinoma
PTHrP = hypercalcaemia
Why is Squamous cell carcinoma more treatable than SCLC?
Metastasises late, usually spreads locally
What % of bronchial carcinomas is adenocarcinoma?
40-45%
Where does adenocarcinoma arise from?
Mucus secreting glandular epithelium
Main RF for Adenocarcinoma
Asbestos exposure
What is Adenocarcinoma NSCLC closely linked to?
Hypertrophic pulmonary osteoarthropathy
-> triad of :
1. clubbing
2. arthritis
3. long bone swelling
Compression of what causes what in Lung cancer
Compression of sympathetic chain (T1-L2) from resp tumour (PANCOAST TUMOUR) - causes ipsilateral Horner’s syndrome
Describe horner’s syndrome
Miosis
Ptosis
Anhidrosis
Right arm weakness
Describe Pemberton’s sign
What does it show?
Raising arms and facial flushing
Shows SVC obstruction due to compression
