resp Flashcards
how does small cell lung cancer cause paraneoplastic syndromes
cell contains neurosecretory granules that can release neuroendocrine hormones leading to paraneoplastic syndromes
sx lung cancer
sob
cough
haemoptysis
clubbing
recurrent pneumonia
wt loss
supraclavicular lymphadenopathy
CXR findings lung cancer
hilar enlargement
peripheral opacity
pleural effusion
collapse
ix lung cancer
CXR
CT chest abdo pelvis
PET-CT
bronchoscopy with bronchial US
histology
mx non small cell lung cancer
surgery
radiotherapy
+/- chemo
mx small cell lung cancer
worse prognosis
chemo and radio
extrapulmonary manifestations lung cancer
recurrent laryngeal nerve palsy
phrenic nerve palsy
SVC ostruction
horners syndrome
SIADH
cushings
increased ca
limbic encephalitis
lambert eaton myasthenic syndrome
what does recurrent laryngeal nerve palsy cause
hoarse voice
what does phrenic nerve plasy cause
weak diaphragm-> sob
features SVC obstruction
facial swelling, sob, distended neck veins
pembertons sign: raising hands over head leads to facial congestio and cyanosis
cause of horners syndrome in lung cancer
pancoast tumour on sympathetic ganglion
features horners syndrome
partial ptosis
anydrosis
miosis
how does sclc cause siadh
ca releases ectopic ADH ->hygponatraemia
how does sclc cause cushings
ca releases ectopic acth
how does lung ca increase calcium
squamous cell carcinoma releases ectopic pth
how does sclc cause limbic encephalitis
ca makes ab (anti-hu) to limbic system -> memory impairment, hallucinations, confusion, seizures
how does sclc lead to lambert eaton myasthenic syndrome
ab made against sclc which attack body
what is mesothelioma
pleura ca
cause mesothelioma
asbestos
mx mesothelioma
palliative chemo
pneumonia features
SOB, cough and sputum, fever, haemoptysis, pleuritic chest pain, delirium, sepsis
O/E: tachy HR and RR, low oxygen, fever, bronchail breath sounds, focal course crackles, dull percussion
CXR pneumonia
consolidation
CURB 65
see if need hospital for pneumonia
C=confusion
U=urea >7
R= RR>/= 30
B = BP <90 systolic or </= 60 diastolic
65 = age >/=
CURB 65 interpretation
0/1=home
2=hosp
3=ICU assess
CURB 65 in community
CRB 65 (no urea)
common causes pneumonia
50% = strep pneumoniae
20% = h.influenza
causes pneumonia in CF
moraxella catarrhalis
psesudomonas
staph aureus
what is atypical pneumonia
cant culture with gram stain, dont respond to penicillin
need macrolides/fluroquines/tetracyclines
organisms causing atypical pneumonia
legionella pneumophillia=legionnaires: from water/aircon, have hyponatraemia
chlamydia psittaci: infected birds
mycoplasma pneumonia: erthema multiforme-target lesions
chlamydia pneumophillia
coxiella burnetti: Q-fever, animal exposure
atypical pneumoniea from aircon/water
legionnaires
atypical pneumonia from infected birds
chlamydia psittaci
atypical pneumonia causing erythema multiforme target lesions
mycoplasma pneumoniae
atypitcal pneumonia from animal exposure
coxiella burnetti
atypical pneumonia causing hyponatraemia
legionella pneumophillia
fungal causes pneumonia
pneumocystis jiroveci
cause pneumonia in bronchiectasis
pseudomonas aeruginosa
tx fungal pneumonia
co-trimoxazole
abx for mild pnuemonia
5d oral amoxicillin or macrolide
abx mod/sev pneumonia
7-10d dual amox and macrolide
complications pneumonia
sepsis
pleural effusion
empyema
lung abscess
death
ix findingd obstructive lung disease
FEV1:FVC ration <75%
differentiating brtween causes obstructive lung disease
reversibilty testing with broncbodilator
reversibility on asthma not copd
causes restrictive lung disease
intersitital disease (pulmonary fibrosis)
sarcoidosis
obesity
MND
scoliosis
ix findings restrictive lung disease
FEV1:FVC ration >75%
reduced FVC
peak flow technique
stand tall
deep breath
good seal
blow hard and fast
best of 3
what is asthma
reversible airways obstruction
bronchoconstriction
sx asthma
episodic
worse at night
dry cough
wheeze and sob
atopy hx
fhx
bilateral widespread polyphonic wheeze
common asthma triggers
infection
exercise
cold
dust
strong emotiions
diagnosis asthma
clinical
reversibility testing and spirometry
fractional exhaled NO
peak flow diary for 2-4w
mx asthma according to BTS/SIGN
- Short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
- Inhaled corticosteroid (low dose) e.g. beclometasone
- Long-acting beta-2 agonists (e.g., salmeterol) or maintenance and reliever therapy (MART)
- Increase the inhaled corticosteroid or add a leukotriene receptor antagonist (e.g., montelukast)
- Specialist management (e.g., oral corticosteroids)
NICE mx chronic asthma
- Short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
- Inhaled corticosteroid (low dose) taken regularly
- Leukotriene receptor antagonist (e.g., montelukast) taken regularly
- Long-acting beta-2 agonists (e.g., salmeterol) taken regularly
- Consider changing to a maintenance and reliever therapy (MART) regime
- Increase the inhaled corticosteroid to a moderate dose
- Consider high-dose inhaled corticosteroid or additional drugs (e.g., LAMA or theophylline)
- Specialist management (e.g., oral corticosteroids)
features moderate acute asthma
PEFR 50-75%
features sev acute asthma
PEFR 33-50%
RR>25
HR>110
cant complete full sentences
features life threatening asthma
PEFR <33%
sats <92%
silent chest
tired
haemodynamically unstable
ABG=normal pCO2/hypoxia
mx moderate acute asthma
nebulised salbutamol
nebulised ipratropium bromide
oral pred or hydrocortisone
+/- abx
mx severe acute asthma
+/- oxygen
nebulised salbutamol
nebulised ipratropium bromide
aminophylline infusion
IV salbutamol
mx severe acute asthma
nebulised salbutamol
nebulised ipratropium bromide
aminophylline infusion
IV salbutamol
Iv magnesium sulphate
HDU/ICU
intubation
what to monitor when on salbutamol neb
K
also increases HR
what is COPD
chronic non-reversible obstruction
sx COPD
chromic sob
cough
sputum
wheeze
recurrent chest infections
reduced TLCO
polycythaemia due to hypoxia
MRC breathlessness scale
- strenuous exercise
- walking up hill
- walking on flat
- stop after 100m flat
- unable to leave house
severity obstruction COPD
- FEV1 >80%
- FEV1 50-79%
- FEV1 30-49%
- FEV1 <30%
mx COPD
- SABA or ipratropium bromide
- if not steroid responsive=LABA+LAMA, steroid responsive=LABA+ICS
- nebs, oral theophylline, oral mucolytics-carbousteine, abx-azithromycin, oxygen
cause of copd exacerbation
often infection
mx copd exacerbation
nebulised salbutamol/ipratropium
steroids (pred)
abx
physio
ABG of acute retainer in COPD
low pH, high co2
ABG chronic retainer COPD
normal pH
high bicarb
oxygen in chronic retainer copd
titrate sats to 88-92%
not too much oxygen as depresses resp drive
what is BiPAP
helps with inspiration and expiration
uses BiPAP
T2RF with low pH and co2 over 6
Ci BiPAP
untx pemothorax
what is CPAP
helps keep airways expanded
uses CPAP
obstructive sleep apnoea
congestive HF
acute pulmonary oedema
what is interstitial lung disease
effects parenchyma->inflammation and fibrosis
ix interstitial lung disease
high resolution CT=ground glass
lung biopsy and histology
sx idiopathic pulmonary fibrosis
sob
dry cough
clubbing
bibasal fine crackles
poor prognosis
mx idiopathic pulmonary fibrosis
pirifenidone: antifibrotic and antiinflammatory
nintedanib: monoclonal ab to tyrosine kinase
causes drug induced pulmonary fibrosis
amiodarone
cyclophosphamide
methotrexate
nitrofurantoin
causes secondary pulmonary fibrosis
alpha 1 antitrypsin deficiency
RA
SLE
systemic sclerosis
what is hypersensitivity pneumonitis
extrinsic allergic alveolitis
type 3 hypersensitivity rxn
ix hypersensitivity pneumonitis
bronchoalveolar lavage=increased lymphocytes and mast cells
causes hypersensitivity pneumonitis
bird fanciers=droppings
farmers=moulder hay
mx hypersensitivity pneumonitis
remove allergen
+/- oxygen
+/- steroids
what is cryptogenic organising pneumonia
bronchiolitis obliterans organising pneumonia
causes bronchiolitis obliterans organising pneumonia
idiopathic
infection
inflammation
medication
allergic
ix cryptogenic organising pneumonia
lung biopsy
features cryptogenic organising pneumonia
SOB
cough
fever lethargy
what does asbestos lead to
fibrogenic and oncogenic
fibrosis, pleural thickening and plaques, adenocarcinoma, mesothelioma
types pleural effusion
exudative: protein >3
transudative: protein <3
causes exudative pleural effusion
lung ca
pneumonia
RA
TB
causes transudative pleural effusion
congestive HF
hypoalbuminaemia
hypothyroid
meigs syndrome
sx pleural effusion
sob
dull percussion
decreased breath sounds
tracheal deviation away
CXR in pleural effusion
blunted costophrenic angle
fluid in lung fissures
mx pleural effusion
conservative if small
pleural aspiration
chest drain
what is empyema
infected pleural effusion
ix empyema
pleural aspiration=pus, pH</=7.2, low glucose, increased LDH
mx empyema
chest drain and abx
what is pneumothorax
air in pleural space
causes pneumothorax
spontaenous
trauma
iatrogenic: biopsy, venilation
infection
asthma
ix pneumothorax
CXR
sx pneumothorax
sudden SOB
pleuritc chest pain
mx pneumothorax
if no sob and <2cm=none
aspiration
if unstable=chest drain
what is a tension pneumothorax
air can only enter not leave, keeps increasing
features tension pneumothorax
tracheal deviation
reduced air entry
hyperresonant percussion
increased HR
decreased BP
mx tension pneumothorax
large bore cannula into 2nd IC soace midclavicular line then chest drain
chest drain triangle of safety
5th IC space
mid axillary line
ant axillary line
just above rib
sx PE
SOB
cough +/- haemoptysis
pleuritic chest pain
hypoxia
increased HR and RR
low grade fever
haemodynamic instability-reduced BP
ABG in PE
resp alkalosis
mx PE
wells score
if unlikey do a d-dimer if positive then ctpa
if likely then ctpa
LMWH (dalteparin) then long term anticoag
long term anticoag after PE
3m if obvious cause and reversible
6m if recurrent/unsure
6m in ca
mx massive PE with haenodynamic compromise
thrombolysis - alteplase, streptokinase
types pulmonary HTN
- primary or connective tissue disease (SLE)
- LHF-MI, HTN
- chronic lung disease - COPD
- pulmonary vascular disease-PE
- other - sarcoidosis, glycogen storage, haem
features pulmonary HTN
SOB
increased HR
syncope
increased JVP
hepatomegaly
oedema
ECG pulmonary HTN
RVH (large RV1, SV4-6)
R axis deviation
RBBB
CXR pulmonary HTN
dilated PA
RVH
ix pulmonary HTN
ECG
CXR
increased NT-proBNF
echo
mx pulmonary HTN
IV prostanoids (epoprostinol)
endothelin receptor antagonists (macifentan)
phosphodiesterase type 5 inhibitors (sildenafil)
what is sarcoidosis
granulomatous inflammation
RF sarcoidosis
young adults or 60y
F
black
lung features sarcoidosis
mediastinal lymphadenopathy
pulmonary fibrosis
pulmonary nodules
systemic features sarcoidosis
fever
fatigue
wt loss
liver features sarcoidosis
nodules
cirrhosis
cholestasis
eye features sarcoidosis
uveitis
conjunctivitis
optic neuritis
skin features sarcoidosis
erythema nodosum
lupus pernio
granuloma
cardiac features sarcoidosis
BBB
heart block
renal features sarcoidosis
stones
nephrocalcinosis
nephritis
CNS features sarcoidosis
nodules
pituitary
encephalopthy
PNS features sarcoidosis
bells palsy
mononeuritis multiplex
bone features sarcoidosis
arthralgia
arthritis
myopathy
lofgrens
erythema nodosum
bilateral hilar lymphadenopathy
polyarthralgia
ix sarcoidosis
bloods: increased ACE, increased ca, increased IL2 receptor, increased CRP, increased Ig
CXR
biopsy and histology
CXR sarcoidosis
hilar lymphadenopathy
histology sarcoidosis
non caseating granuloma with epithelioid cells
mx sarcoidosis
resolves spontaneously
oral steroids
methotrexate
azathioprine
what may sarcoidosis progress to
pulmonary fbrosis
pulmonary HTN
features obstructuve sleep apnoea
apnoea in sleep
snoring
morning headache
unrefreshing sleep
daytime sleepiness
reduced concentration
low oxygen sats in sleeo
what can obstructive sleep apnoea cause
HTN
HF
MI
stroke
ix obstrucitve sleep apnoea
sleep studis
mx obstrucitve sleep apnoea
reduce RF - wt, alcohol, smoking
CPAP
surgery
features chronic retainer COPD
increased carbon dioxide and bicarb and normal pH on ABG
oxygen sats goal chronic retainer COPD
88-92%
oxygen sats goal in someone with COPD who doesnt chronicly retain
normal goal
vaccines for people with COPD
pneumococcal one off
annual influenza
Wells PE criteria
clinical signs or symptoms DVT=3pt
PE number one diagnosis = 3pt
HR>100 = 1.5pt
immobilisation >/=3d or surgery in prev 4 weeks =1.5pt
prev PE/DVT = 1.5pt
haemoptysis = 1pt
malignancy with tx within 6m or palliative =1pt
interpretation wells PE
0-4=unlikely, do d-dimer, if raised ctpa
4+ = likely do do ctpa
saddle PE
important to recognise as leads to RHF and death
large, straddles bifurcation of pulmonary trunk
complete occlussion PE
completely blocks artery
segmental PE
affects distal arterial branches
chronic PE
peripheral not central
silhouette sign CXR
loss usual clear differentiation
L lower lobe collapse features CXR
sail sign=double L heart border
R upper lobe collapse features CXR
horizontal fissure and R diaphragm shifted up
R lower lobe collapse features CXR
double R heart border
L upper lobe collapse features CXR
veil over L upper lobe and L diaphragm shifted up
R middle lobe collapse features CXR
lost R heart border
R middle and lower lobe collapse features CXR
lost R heart border and R hemidiaphragm
causes lobar collapse
paeds: snot, foreign body
adults: cancer, infection, snot
effusion with pH <7.2
empyema
features pneumothorax CXR
can see a lung edge
too black
lung markings not to edge
features bullous emphysema CXR
no lung edge
too black
no lung markings
is chronic change usualy due to smoking
pulmonary mets CXR
multiple bilateral soft tissue nodules
abscess or cavitating tumout features CXR
solitary well circumscribed lesion dense in middle then white around it
commonest cause HAP
aerobic gram negative bacilli - pseudomonas aeruginosa, klebsiella pneumoniae
commonest cause COPD exacerbation
h. influenzae
CXR TB
patchy nodal shadows
cavitating lesions
air space consolidations
nodules
how to check if TB rifampicin resistant
molecular assay
how does rifampicin work
inhibits DNA transcription
how does isoniazid work
inhibits synthesis cell wall
how does pyrazinamide work
lowers intracellular pH - disrupting synthesis fattu acids
how does ethambutol work
interferes with cell wall synthesis
