Resp Flashcards
1
Q
Causes of COPD
A
CIGARETTE SMOKING!
Chronic exposure to pollutants
Alpha-1-antitrypsin deficiency
2
Q
Types of COPD
A
Chronic bronchitis and Emphysema
3
Q
How do you define chronic bronchitis?
A
Cough with sputum for 3 or more months for 2 or more years
4
Q
State a characteristic of parapneumonic effusion
A
Exudative (> 35 g/L protein)
5
Q
RF COPD
A
SMOKING
Recurrent lung infections
Environmental tobacco smoke
Genetics
Age
Socio-economic status
Occupational dust and chemical inhalation
6
Q
Describe the MRC Dyspnoea Scale
A
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
7
Q
Pink puffer signs/symptoms
A
Weight loss
Barrel-chested
Thin (low BMI)
Emphysematous
Pursed lips
Normal PaO2
8
Q
Blue bloater sign/symptoms
A
Cough w/ phlegm
Cyanosis
Overweight
Low PaO2
9
Q
Ix COPD
A
- 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
10
Q
Key presentation of COPD
A
Productive cough with white or clear sputum, wheeze and breathlessness
Following years of smoker’s cough!!
11
Q
Tx COPD
A
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
12
Q
When should LTOT be given?
A
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
13
Q
Describe how LTOT should be given
A
> 15 hrs/day
14
Q
What surgery can be done for Px with COPD?
When is this most effective?
A
Lung volume reduction surgery
In Px with upper lobe emphysema and low exercise capacity
15
Q
What treatment should you avoid in COPD Px?
A
Chronic treatment with systemic corticosteroids
bc the benefit to risk ratio is too low
16
Q
What prophylaxis treatments are offered for COPD Px? Why?
A
Influenza and pneumococcal vaccines
Bc exacerbations caused by recurrent resp diseases
17
Q
Stages of COPD
A
FEV1 % - compared to predicted value
STAGE 1 - ≥ 80% (mild)
STAGE 2 - 50 - 79% (moderate)
STAGE 3 - 30 - 49% (severe)
STAGE 4 - < 30% (v severe)
18
Q
What might an XR show for a COPD patient?
A
*Low, flattened diaphragm
Long narrow heart shadow
↓ Peripheral lung markings
Bullae
*HYPER-INFLATED LUNGS
19
Q
DDx COPD
A
Asthma
Congestive heart failure
Bronchiectasis
Pneumoconiosis
Asbestosis
20
Q
What are the most common causes of COPD exacerbations?
A
Viral upper respiratory tract infections
Infections of tracheobronchial tree
21
Q
Ix COPD exacerbations
A
ABG
Chest radiographs
ECG
Bloods - WBC count
22
Q
Tx COPD exacerbations
A
O2 - target = 88 - 92% !!
Bronchodilators - SABA and/or SAMA
Antibiotics
potentially Non-Invasive ventilation
23
Q
When should antibiotics be given for COPD exacerbations?
A
3 cardinal signs :
1. ↑ Dyspnoea
2. ↑ Sputum vol
3. ↑ Sputum purulence
24
Q
Why is the O2 target sat lower for COPD patients?
A
Bc of low respiratory drive
∴ can cause hypercapnia is O2 target sat is normal (94-98%)
25
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
26
COPD is characterised by ?
Neutrophilic inflammation
27
Asthma is characterised by?
Eosinophilic inflammation
28
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
29
Types of asthma
Allergic / Eosinophilic (70%)
Allergens & atophy
Non-allergic / Non-Eosinophilic (30%)
Exercise, cold air, stress, obesity
30
What age does asthma usually present itself?
Starts in childhood, 3-5 years
Peak prevalence is 5-15 years
31
Which countries have a higher prevalence of Asthma?
New Zealand, UK, Australia
(HICs)
32
Name some precipitating factors of Asthma
Occupational
Cold air/water
Exercise
Pollution/irritant dust
Emotion
Drugs - NSAIDs, aspirin
33
Which hypersensitivity reaction is Asthma?
TYPE 1
34
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
35
Key presentation of Asthma
Cough, Dyspnoea, tight chest
DIURNAL VARIATION
Bilateral wheeze on auscultation
36
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
37
Associated symptoms of Asthma!
Atopic triad : Asthma, Hayfever, Eczema
Samter's tried : Asthma, Aspirin allergy, Nasal Polyps
38
Ix Asthma
Same as COPD
Multiple peak flow measurement required!!
39
How are mast cells involved in asthma?
When IgE binds to mast cell receptor, mast cell responds to allergen binding to IgE
∴ releases chemicals
40
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
41
Describe the microscopy of the mucus of an Asthma patient
Curshmann spirals
Charcot-Leydig crystals
42
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
43
Tx Asthma
1. SABA
2. SABA + ICS
--------------------------- check their technique!!
3. SABA + ICS + LTRA
4. SABA + ICS + LABA +/- LTRA
5. ↑ ICS dose
6. Maybe another drug e.g. omalizumab anti-IgE antibody
44
Tx for acute asthma attack
**O SHIT ME**
**O**xygen
**S**ABA
**H**ydrocortisone (ICS)
**I**pratropium bromide
**T**heophylline
**M**gSO4
**E**scalate care
45
Draw the graph of different types of lung cancer
do it
46
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?
47
Where are the majority of TB cases?
Africa and Asia (India, China)
48
What's the cause of death for most people with HIV?
Tuberculosis
49
Name the 4 main causes of TB
*Mycobacterium tuberculosis
Mycobacterium bovis
Mycobacterium africanum
Mycobacterium microti
50
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**
51
How is cystic fibrosis inherited?
Autosomal recessive
52
Cause of Cystic fibrosis
Mutation of chromosome 7 - codes for CFTR protein
53
RF Cystic fibrosis
Caucasian !
FHx
54
Presentation of Cystic fibrosis
Resp - recurrent infections, bronchiectasis
Neonates - jaundice, failure to thrive, meconium ileus
GI - Bowel obstruction, steatorrhoea
Other - male infertility, DM
55
Other than respiratory problems, what other systemic problem do Px with cystic fibrosis have?
Pancreatic insufficiency
56
What is a common ECG finding for pulmonary embolism?
Sinus tachycardia
57
Why does PE cause tachycardia?
Body attempts to increase cardiac output to compensate for hypoxia
58
Key presentation of cystic fibrosis
Cough
Thick mucus production
Pancreatic insufficiency - poor weight gain, steatorrhoea
SALTY SWEAT
59
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
60
Ix Cystic fibrosis
Lung function test
Faecal elastase test
**GS :** Sweat test - Na+ and Cl- > 60 mmol/L
61
Screening test of Cystic fibrosis
Genetic newborn screen - used in countries w ↑ prevalence or CF family history
Measures immunoreactive trypsinogen (IRT), neonatal heel prick
62
Why does pancreatic insufficiency cause steatorrhoea?
Enzymes are not released to digest fat
∴ Fatty stools
63
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
64
What Abx is commonly used against S. Aureus?
Flucoxacillin
65
What Abx is commonly used against H. Influenzae?
Amoxicillin
66
What Abx is commonly used against Psuedomonas aeruginosa?
Ciprofloxacin
67
What are good prognostic markers for CF?
Lung function (FEV1) and BMI
68
What Abx is commonly used against MRSA?
Rifampicin and Fucidin
69
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
70
Complications of CF
Bronchiectasis, infections
71
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
72
What is Sarcoidosis?
Interstitial lung disease, disease of alveolar/capillary interface
Immune response occurs repeatedly without a pathogen triggering it, cause not entirely known
73
Epidemiology of Sarcoidosis
20 - 40 years
F > M
African-Caribbeans more affected
74
RF Sarcoidosis
African American
FHx
Prior infection with M. tuberculosis
75
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
76
What organs do sarcoidosis affect?
Can affect any organs but mostly lungs
77
State some common extrapulmonary manifestations of Sarcoidosis
Ant. uveitis, erythema nodosa, skin papule, peripheral lymphadenopathy, hepatosplenomegaly
78
State some less common extrapulmonary manifestations of Sarcoidosis
Bone, heart (arrhythmias), CNS (Bell's palsy), kidneys
79
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
80
DDx Sarcoidosis
RA
Lymphoma
Metastatic malignancy
TB
Lung cancer
SLE
Idiopathic pulmonary fibrosis
Multiple myeloma
81
Tx Sarcoidosis
In early stages, can resolve spontaneously
If persistent - steroids (prednisolone)
Transplant if extreme
82
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)
83
Which Sarcoidosis patients do NOT require Tx?
Symptomatic patients, Stage 1
Asymptomatic patients, Stage 2 or 3
84
When is the mean onset of Idiopathic pulmonary fibrosis?
60s
Presentation is very uncommon < 50 years
85
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
86
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
87
Key presentation of Idiopathic pulmonary fibrosis
Exertional dyspnoea, dry cough, bibasal crackles
88
Other signs/symptoms of Idiopathic pulmonary fibrosis
Weight loss
Arthralgia
Cyanosis
Clubbing
89
DDx Idiopathic pulmonary fibrosis
COPD
Asthma
Bronchiectasis
CHD
Lung cancer
Hypersensitivity pneumonitis
Asbestosis
90
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
91
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
92
What other Ix can you do for Idiopathic pulmonary fibrosis?
Lung biopsy
93
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
94
Prognosis Idiopathic pulmonary fibrosis
Median survival= 2-5years
95
What is Idiopathic pulmonary fibrosis also known as?
Cryptogenic organising pneumonia
96
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)
97
Key presentation of Bronchiectasis
Chronic cough with large amounts of green foul-smelling sputum
98
Other signs/symptoms of Bronchiectasis
Wheeze
Intermittent haemoptysis
Clubbing
Crackles over affected areas (esp base of lungs)
Recurrent chest infections
Dyspnoea
Chest pain
99
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**
100
GS Ix Bronchiectasis
**HIGH RES CT** - thickened, dilated bronchi w/ cysts
**airways larger than associated blood vessel**
101
Epidemiology Bronchiectasis
F > M
May develop after lung infections
Pathological end point of many diseases
Presents at any age but incidence ↑ with age
102
What are some major pathogens in Bronchiectasis?
Haemophilus influenza
Strep. pneumoniae
Staph. aureus
P. aeruginosa
103
Tx Bronchiectasis
Improve mucus clearance - chest physio, postural drainage
Bronchodilators - nebulised SABA
Prophylactic Abx
Anti-inflammatory agents e.g. azithromycin (reduces exacerbation freq)
104
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
105
Abx for Pseudomonas aeruginosa (exacerbation of Bronchiectasis)
Oral ciprofloxacin
106
What causes Bronchiectasis exacerbations?
H. influenzae
S. aureus
107
Abx for H. influenzae (exacerbation of Bronchiectasis)
Oral amoxicillin, co-amoxiclav, doxycycline
If multi-resistant, needs IV cephalosporin
108
Abx for S. aureus (exacerbation of Bronchiectasis)
Flucloxacillin
109
How much fluid in pleural space in Pleural effusion to be detected clinically?
500 ml
110
How much fluid in pleural space in Pleural effusion to be detected via CXR?
300 ml
111
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
112
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
113
Pleural effusion lymphatic causes
Damage during surgery
Malignancy
114
What is the function of the pleura?
Allows movement of lung against chest wall
Clears fluid from pulmonary interstitium
115
What does pleural fluid contain ?
Proteins - albumin, globulin, fibrinogen
Many mesothelial cells, monocytes, lymphocytes
116
When are recurrent pleural effusions seen?
In malignant mesothelioma
117
RF Pleural effusion
Prev lung damage
Asbestos exposure
118
Describe transudative fluid
LESS PROTEIN
< 30 g/L
∴ Appears **clear** in thoracentesis
119
Describe exudative fluid
MORE PROTEIN
< 30 g/L
∴ Appears **cloudy** in thoracentesis
120
Key presentation of pleural effusion
Can be asymptomatic
Dyspnoea on exertion, pleuritic chest pain, cough
121
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
122
Ix Pleural effusion
CXR :
Transudate - bilateral
Exudate - unilateral
Costophrenic angle blunt
**Thoracentesis** or **pleural tap**
123
Tx Pleural effusion
Depends on cause
CHF - loop diuretics
Infective - Abx
Malignant - therapeutic thoracentesis
For large effusions - CHEST DRAIN ! 5TH intercostal space
124
How can you prevent reaccumulation of pleural effusion?
Pleurodesis e.g. tetracycline
causes adhesion of visceral and parietal pleura
125
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
126
What is a huge contraindication of thrombolysis in the history of a patient?
A haemorrhagic stroke at ANY TIME IN THEIR LIFE
127
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
128
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
129
Pneumonia with associated pleural effusion is called what?
Parapneumonic effusion
130
Describe the 3 forms of parapneumonic effusion
1. **Simple** (non-infected) - resolves spontaneously, not Tx req
2. **Complicated** (infected) - reqs drainage/intra pleural fibrolytics/surgery
3. **Empyema** - reqs drainage/intra pleural fibrolytics/surgery
131
Types of pneumothorax
Spontaneous
Traumatic
Iatrogenic
Lung pathology
Tension
132
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
133
Ix Pneumonia
FBC - ↑ WBC
Sputum culture
**GS :** CXR - localised/widespread consolidation, effusion, abscesses, empyema
Air bronchogram
134
What does rusty sputum indicate?
S. pneumoniae
135
When might pneumonia present with a rash?
If mycoplasma
136
In a pneumonia patient with HIV or immunocomp, what bacteria would we assume is the cause?
Pneumocystic jiroveci
137
Pneumonia : water cooler/air conditioner/SPAIN
What bacteria?
Legionella pneumophilia
138
If a patient has CAP, most likely causal bacteria?
**Step. Pneumoniae
H. influenzae
139
If a patient has HAP, most likely causal bacteria?
**Gram neg bacteria** -
Pseudomonas
E.coli
Klebsiella
Staph. aureus (incl MRSA)
140
Describe pathophysiology of Pneumothorax
Usually pleural space has negative intrapleural pressure
Breach in pleura causes flow of air into pleural space
141
Key presentation of Pneumothorax
Dyspnoea, one sided sharp pleuritic pain
Hyperresonant percussion note ipsilaterally
Reduced breathing sounds
142
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 !!!!!!!!!!!!!!
143
Key presentation of tension pneumothorax
Cardiopulmonary deterioration : Hypotension, Resp disease, Low O2 sats, Tachycardia, Shock
144
Tx Tension pneumothorax
Large bore cannula into pleural space through 2nd intercostal space in midclav line
145
Define pulmonary hypertension
Resting mean pulmonary arterial pressure **(mPAP) > 25 mmHg**
Mild : 25-40
Moderate : 40 - 55
Severe : 55+
146
Causes of pulmonary HTN
Precapillary - 1º pul HTN, pul amboli
Capillary - COPD, asthma
Post capillary - LV failure
Chronic hypoxaemia - COPD, high altitude
147
Key presentation of Pul HTN
Exertional dyspnoea + Fatigue FIRST
then RV failure (JVP distention, periph oedema, cannon A waves)
148
What is a cannon A wave?
Large amplitude waves seen in jugular vein
149
Ix Pul HTN
**GS :** RH catheter
measures pressure directly
CXR - RVH
ECG - RA dilation (p = pulmonale, peaked p waves)
150
Tx Pul HTN
Sildenafil - viagra!
-> Phosphodiesterase 5 inhibitor
151
HAEMOPTYSIS + HAEMATURIA =
GOODPASTURE'S
152
Ix Goodpasture's
**Serology - Anti-GBM antibody POS**
153
What's a side effect of ICS inhalers?
oral thrush
154
What type of hypersensitivity reaction of Hypersensitivity pneumonitis?
Type III
155
Ix Hypersensitivity Pneumonitis
Usually diagnosed through Hx and examination
CXR - patchy, nodular infiltrates, fibrosis
156
Tx Hypersensitivity Pneumonitis
Remove allergen!!
Steroids
157
How is A1AT-def inherited?
Autosomal recessive
158
How is CF inherited?
Autosomal recessive
159
What would you see in a Patient's CT with COPD with A1AT-deficiency as the cause?
Panacinar emphysema
160
What would you see on a CT of a patient with Emphysema?
Centriacinar (resp bronchioles inv. ONLY - smokers!!)
Panacinar (A1AT def!)
161
Where is EMPYEMA seen?
CXR on Pneumonia patient
162
What is EMPHYSEMA?
Type of COPD
163
RF Bronchiectasis
Infection
CF
Lung cancer
164
Males, 40-70 with asbestos exposure decades ago, dyspnoea
What do you immediately suspect?
MESOTHELIOMA
165
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
166
Ix Lung cancer
1st line - CXR, then CT
pleural thickening +/- effusion
**GS :** BRONCHOSCOPY and BIOPSY
167
What might be raised non-specifically in mesothelioma?
Usually associated with ovarian cancer
CA-125
168
Tx Mesothelioma
Why?
Purely palliative :(
v severe aggressive cancer! v low survival rates
169
What type of people get SCLC?
ONLY SMOKERS!
170
Name 3 paraneoplastic syndromes of SCLC
Cushing's - ACTH
SIADH - ADH
Lambert-Eaton syndrome - dysfunction of ACh at nmj
171
What % of bronchial carcinomas are SCLC?
15%
172
Where does SCLC affect?
Central resp system (bronchi)
173
How does SCLC appear on biopsy?
Small cells w/ minimal cytoplasm
174
Tx SCLC
If caught early, chemo/radiotherapy
Usually palliative
175
What % does Squamous cell carcinoma account for bronchial carcinoma?
30-35%
176
Where does squamous cell carcinoma arise from?
Lung epithelium
177
**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
178
What does squamous cell carcinoma appear as on biopsy?
Histologically resembles squamous epithelium
179
Who does Squamous cell carcinoma mainly affect?
Smokers
180
Paraneoplastic syndrome of Squamous cell carcinoma
PTHrP = hypercalcaemia
181
Why is Squamous cell carcinoma more treatable than SCLC?
Metastasises late, usually spreads locally
182
What % of bronchial carcinomas is adenocarcinoma?
40-45%
183
Where does adenocarcinoma arise from?
Mucus secreting glandular epithelium
184
Main RF for Adenocarcinoma
Asbestos exposure
185
What is Adenocarcinoma NSCLC closely linked to?
Hypertrophic pulmonary osteoarthropathy
-> triad of :
1. clubbing
2. arthritis
3. long bone swelling
186
Compression of what causes what in Lung cancer
Compression of sympathetic chain (T1-L2) from resp tumour (PANCOAST TUMOUR) - causes ipsilateral **Horner's syndrome**
187
Describe horner's syndrome
Miosis
Ptosis
Anhidrosis
Right arm weakness
188
Describe Pemberton's sign
What does it show?
Raising arms and facial flushing
Shows SVC obstruction due to compression
