Resp Flashcards
what is asthma?
chronic inflammatory disease of airway hypersensitivity and variable, reversible obstruction
what are 6 triggers of asthma?
viral/bacterial infection
allergen exposure
exercise
Night/early morning
Cold, damp, dust
Strong emotion
what are 2 medications that can worsen asthma?
Beta blockers
NSAIDs
what are 6 risk factors for asthma?
FHx
Atopic Hx
Low birth weight
not breastfed
Second hand smoke
High concentration allergens - dustmites
what are 5 presentations of asthma?
Diurnal episodic SOB
Dry cough
Chest tightness
Wheeze
Symptoms are reversible with bronchodilators
how is asthma investigated in adults?
1 - eosinophil count raised OR FeNO >50 ppb
2 - spirometry - FEV1 >12% postdilator increase or >10% over predicted normal
3 - PEF 20% variability over 2 weeks
what are the 2 different types of asthma?
Eosinophilic - most common (70%)
non-eosinophilic
what is atopy?
when an individual readily develops IgE against common environmental antigens
what is non-eosinophilic asthma triggered by?
exercise, cold air, stress, smoking, obesity, menstrual cycle
what is eosinophilic asthma triggered by?
allergens
what drug class should you never give to asthmatics?
BETA BLOCKERS
what 4 immune cells are present in asthma?
mast cells
eosinophils
dendritic cells
lymphocytes
what is one feature of a moderate asthma atack?
peak flow 50-70% best/predicted
what are 4 features of a severe asthma attack?
inability to complete sentences
pulse >110
RR >25
PEFR 33-50%
what are 6 features of a life threatening asthma attack?
silent chest, cyanosis, poor rest effort
confusion and exhaustion
Bradycardia
O2 Sats <92%
PEFR <33%
Normal pCO2
what is the management for a mild asthma exacerbation?
INH Salbutamol via spacer
Increased ICS dose/oral prednisolone 40-50mg 5 days
f/u within 48 hours
what is the management of a moderate asthma exacerbation?
Hospital
Nebulised salbutamol back to back
Oral/IV pred/hydrocortisone
what is the management of severe asthma exacerbations?
Hospital
O2
Nebulised ipratropium bromide
IV magnesium sulphate
IV salbutamol
IV aminophylline
intubation and ventilation
what are 3 criterial needed for discharge after an acute asthma exacerbation?
stable on discharge medication for 12-24 hours - no O2 or Nebs
INH technique checked
PEF >75% best or predicted
what are 2 effects of excessive salbutamol administration?
hypokalaemia
Lactic acidosis - due to tachycardia
how is asthma diagnosed with peak flow?
a greater than 15% increase in FEV1 or PEFR following bronchodilator inhalation
how do B2 agonists work?
binds to B2 receptor coupled with Gs protein
=> adenyl cyclase converts ATP to cyclic AMP =>
increases in cyclic AMP leads to bronchodilation
how do muscarinic antagonists work?
act on M3 receptors
prevent Ach from binding => no smooth muscle contraction
what are 6 side effects of corticosteroids?
susceptibility to infection
osteoporosis and muscle wasting
cataracts
diabetes
skin thinning and bruising
growth retardation
what is the stepwise medical management of asthma in >12 years?
1 - ICS (budesonide) + LABA (formoterol) combined inhaler - anti-inflammatory reliever (AIR) therapy
2 - low dose MART
3 - moderate dose MART
4 - if FeNO or blood eosinophil raised - refer to specialist OR if not raised try adding LTRA OR LAMA
5 - refer
what is classed as moderate ICS dose?
400-800 micrograms budesonide or equivalent
what is classed as high dose ICS?
> 800 micrograms budesonide or equivalent
what are 3 complications of asthma?
severe exacerbation
airway remodelling
candida due to inhaled corticosteroids
what is the most common causative pathogen in pneumonia?
streptococcus pneumoniae
2 - haemophilus influenzae
what are 4 other pathogens that cause pneumonia?
Moraxella catarrhalis
Pseudomonas aeruginosa - CF or bronchiectasis
Staph aureus - CF
MRSA - in HAPs
what are 6 manifestations of pneumonia?
Cough
Sputum production
SOB
pleuritic chest pain
Fever
Haemoptysis
what are 3 signs of pneumonia on auscultation?
Bronchial breath sounds
Focal coarse crackles
Dullness to percussion
what assessment tool is used to assess pneumonia severity?
CURB65
what is the CURB65 score?
predicts mortality in pneumonia
Confusion
Urea ≥7mmol/L
Respiratory rate≥ 30/min
Blood pressure; low systolic < 90mm/Hg or diastolic ≤60mm/Hg
Age ≥ 65
1 - low risk (<3%)
>2 - Intermediate risk (3-15%)
>3 - High risk (>15%)
what are 3 risk factors for CA pneumonia?
> 65 years
resident in healthcare setting
COPD
what are 6 complications of pneumonia?
Sepsis
ARDS
Pleural effusion
Empyema
Lung abscess
Death
what are 5 risk factors for pneumonia?
extremes of age
smoking
Chronic resp diseases
immunosuppression
Aspiration risk
what is the management of low severity CA pneumonia?
1 - Amoxicillin 500mg TDS 5 days
PENICILLIN ALLERGY
- Doxycycline 200mg 1st day the 100mg OD for 4 more days
- Erythryomycin 500mg QDS 5 days - PREGNANCY
What is the management of moderate severity CA pneumonia?
1 - Oral Amoxicillin 500mg TDS
AND
Clarithromycin 500mg BD 5 days
OR
Erythromycin 500mg QDS in pregnancy
PENICILLIN ALLERGY
- Doxycycline 200mg first day then 100mg OD
what is the management of severe CA pneumonia?
IV Co-amoxiclav AND Clarithromycin
PEN ALLERGY - doxycycline, clarithromycin, erythromycin
what are CXR findings in pneumonia?
opacification of air spaces - initially patchy but becomes confluent
Complications - pleural collection, cavitation
when should adults with previous pneumonia get x-ray follow up?
After 6 weeks if
Persistent symptoms despite treatment
higher risk of underlying malignancy - >50 years, smoker
what is COPD?
a progressive disease state characterised by airflow limitation that is not fully reversible. Contains both emphysema and chronic bronchitis
what are 3 risk factors for COPD?
smoking
older age
genetics - alpha-1 antitrypsin
why is there increased mucous secretion in COPD?
increased goblet cell size and number
what are 5 manifestations of COPD?
SOB
Cough
Sputum
Wheeze
recurrent resp infections
what scale can be used for assessing breathlessness in COPD?
MRC Dypnoea scale
what is the grading of the MRC dyspnoea scale?
1 - breathless on strenuous exercise
2 - breathless walking uphill
3 - breathless on flat
4 - breathless <100m
5 - Unable to leave house
what FEV1/FVC ratio is needed for an obstructive lung disease?
<0.7
what FEV1/FVC ratio is needed for a restrictive lung disease?
> 0.7
what is the 1st line Ix for COPD?
spirometry - <0.7 AND non reversible
what might be seen on CXR in COPD?
Hyperinflation
Bullae
Flat hemidiaphragm
Also need to exclude lung cancer
what is the severity grading of COPD?
using FEV1
1 - mild - FEV1 >80% predicted
2 - moderate - FEV1 50-79% predicted
3 - severe - FEV1 30-49% predicted
4 - very severe - FEV1 <30% predicted
what 2 vaccinations should people with COPD get?
Pneumococcal
Anual flu
what is the initial medical management of COPD?
1 - SABA + SAMA (ipratropium)
what 4 things determine if COPD may have steroid responsive features?
previous Dx asthma/atopy
FEV1 variation >400mls
Diurnal variation in peak flow >20%
Raised blood eosinophils
what is the 2nd line management of COPD without steroid responsive features?
LABA + LAMA
Anoro ellipta
Ultibro breezhaler
Duaklir genuair
what is the 2nd line management of steroid responsive COPD?
LABA + ICS
Fostair
Symbicort
Seretide
what is the final inhaler combination in either steroid or non-steroid responsive COPD?
Tripple therapy - LABA + LAMA + ICS
Trimbow
Trelegy ellipta
Trixeo aeosphere
what Abx can be given as prophylaxis in COPD?
Azithromycin
what are 2 things that need monitoring with azithromycin use?
ECG - can cause long QT
LFTs
who is eligible for rescue medications in COPD?
exacerbation within last year
understand how to take and risk and benifits
know when to seek help and ask for replacements
when are phosphodiesterase-4 inhibitors recomended in COPD?
roflumilast
severe disease - FEV1 <50% predicted
AND
2+ exacerbations in past year despite maximal therapy
what are 4 criteria for LTOT in COPD?
Chronic hypoxia
Polycythaemia
Cyanosis
Cor pulmonale
what is needed on ABG for LTOT?
pO2 <7.3
OR
pO2 7.3-8 PLUS polycythaemia, peripheral oedema OR pulmonary HTN
what is cor pulmonale?
right sided heart failure de to respiratory disease
increased pressure in the pulmonary arteries limits R ventricular action which causes back pressure into R atrium, vena cava and systemic venous system
what are 5 causes of cor pulmonale?
COPD - most common
PE
Interstitial lung disease
CF
primary pulmonary hypertension
what are 8 clinical manifestations of cor pulmonale?
Hypoxia
Cyanosis
Raised JVP
Peripheral oedema
Raised JVP
Peripheral oedema
Parasternal heave
loud S2
Murmurs - pansystolic - tricusp regurg
Hepatomegally
what are ABGs like in COPD exacerbation?
Acidosis
Low pO2 - hypoxia and resp failure
Raised pCO2 - retention
Raised bicarb - if chronic retention
what is the O2 concentration of room air?
21%
what is the O2 concentration of different venturi?
Blue 24%
White 28%
Orange 31%
Yellow 35%
Red 40%
Green 60%
what is the management of an acute exacerbation of COPD?
INH/Neb - Salbutamol + ipratropium
Prednisolone 30mg 5 days
respiratory physio
Abx - if indicated
IV aminophylline
NIV
Intubation and ventilation
what are 3 first line antibiotics in IE COPD?
Amoxicillin, clarithromycin, doxycycline
what medication can be used as a respiratory stimulant in COPD if NIV/intubation if not indicated?
Doxapram
what are 3 inclusion criteria for NIV in COPD?
Persistent resp acidosis despite maximal medical management
potential to recover
acceptable to patient
what investigation needs to be done before initiating NIV?
CXR - exclude pneumothorax
what are 3 contraindications to NIV?
pneumothorax
structural abnormalities
pathology of face, airways or GI tract
what is alpha-1 Antitrypsin Deficiency?
rare genetic condition causing lung and liver problems
early onset COPD/cirrhosis even without smoking/drinking Hx
autosomal co-dominant
What are the 4 stages of COPD?
1 - FEV1 >80% predicted
2 - FEV1 50-79%
3 - FEV1 30-49%
4 - FEV <30%
what are 3 complications of COPD?
Cor pulmonale
resp failure
pneumothorax
what is HA pneumonia?
an acute lower respiratory tract infection that is acquired after at least 48 hours of admission to hospital
what is the most common cause of early onset HA pneumonia?
pseudomonas aeruginosa
< 5 days after admission
what is the most common late onset HA pneumonia?
S. Aureus
> 5 days after admission
what are 3 risk factors for HA pneumonia?
poor infection control/hand hygiene
intubation and mechanical ventilation
decreased consciousness
what extra tests do you have to do in HA pneumonia?
sputum culture
nasopharyngeal swap
tracheal aspirate samples
BEFORE antibiotics
what is the management of HA pneumonia?
7-10 days of
Co-amoxiclav
Ceftriaxone
Pipericillin with tazobactam
PLUS Clarithromycin
what is pleural effusion?
fluid collection between the parietal and visceral pleural surfaces of the thorax
what is the most common cause of pleural effusion?
heart failure
what are 3 risk factors for pleural effusion?
pneumonia
malignancy
PE
what are 5 manifestations of pleural effusion?
SOB
dullness to percussion
pleuritic chest pain and rub
reduced breath sounds
Tracheal deviation away - if v large
what are 3 investigations of pleural effusion?
PA and Lateral CXR
US
Contrast CT - for underlying cause
what is seen on PA CXR in pleural effusion?
Blunting of costophrenic angles
Fluid in lung fissures
Meniscus in larger effusions
Tracheal deviation away in V large effusions
what is the management of pleural effusion?
Conservative if small
Pleural aspiration - thoracentesis
Chest drain
what should be used in a pleural aspiration?
21G needle and 50ml syringe
what is the normal amount of pleural fluid?
5-10ml
what criteria determines whether something is a transudate or exudate?
lights criteria
what are light’s criteria for exudative effusions?
Pleural fluid protein/serum protein >0.5
Pleural fluid lactate dehydrogenase / serum LDH >0.6
Pleural fluid lactate dehydrogenase > 2/3rds normal upper limit serum LDH
what are 3 complications of pleural effusion?
pneumothorax
empyema
trapped lung
what classes as a transudate?
Pleural fluid with protein content <30g/L
what are 4 causes of transudates?
Congestive heart failure
Hypoalbuminaemia
Hypothyroidism
Meigs syndrome
what is meigs syndrome?
TRIAD
Benign ovarian tumour
Pleural effusion
Ascites
resolves with removal of tumour
what are exudates?
Pleural fluid with protein content >30g/L
what are 4 causes of exudates?
Lung cancer/mesothelioma
Pneumonia
Rheumatoid arthritis + SLE
TB
Pancreatitis
PE
Dressler’s syndrome - pericarditis after MI
what is empyema?
an infected pleural effusion - pus, low pH, high LDH
Tx - chest drain and ABx
what are 4 risk factors for pneumothorax?
smoker
FHx
previous pneumothorax
tall and thin
what are 4 causes of pneumothorax?
Primary spontaneous - due to rupture of subpleural bleb/bullae
Secondary spontaneous - pre-existing lung condition, due to rupture of pulmonary tissue
Trauma
Iatrogenic - lung biopsy, mechanical ventilation, central line insertion
Pathology - infection, asthma, COPD
what are 6 manifestations of pneumothorax?
Sudden onset pleuritic chest pain
Sudden onset SOB
Tachycardia and Tachypnoea
Cyanosis
Hyperresonance
Reduces breath sounds
what is a tension pneumothorax?
severe pneumothorax resulting in displacement of mediastinal structures resulting in severe respiratory distress and haemodynamic collapse
what is a catamenial pneumothorax?
pneumothorax occuring in menstruating women thought to be due to endometriosis within thorax
what are 4 extra clinical manifestations of tension pneumothorax?
ipsilateral hyper expansion
contralateral tracheal deviation
hypotension
respiratory distress
shock
what is seen on CXR in pneumothorax?
loss of lung markings and shrunken lung edge
in tension - mediastinal shift and tracheal deviation
Should measure size of pneumothorax horizontally from lung edge to inside of chest wall at level of hilum
what is the gold standard investigation for pneumothorax?
CT chest
what is the management for low risk small pneumothorax?
No/Minimal symptoms (<2cm pneumothorax)
CONSERVATIVE MANAGEMENT
Priamary - r/v every 2-4 days as OP
Secondary - monitor as inpatient
what are 6 features of a high risk pneumothorax?
haemodynamic compromise
significant hypoxia
bilateral pneumothorax
Underlying lung disease
>50 years + Smoker
Haemothorax
what are the management options for pneumothorax without high risk features where it is safe to intervene?
Conservative management - if minimal symptoms
Pleural vent ambulatory device
Chest drain
what is the management of high risk safe to intervene pneumothorax?
chest drain
when is it safe to intervene in a pneumothorax?
2cm lateral or apical on CXR
any size on CT which can be safely accessed with radiological support
what is the follow up of a pneumothorax with needle aspiration/chest drain?
OP f/u 2-4 weeks
where are chest drains inserted?
triangle of safety
- 5th intercostal space
- mid-axillary line
- anterior axillary line
just above rib to avoid neurovascular bundle
X-ray to check insertion site
what is a swinging chest drain?
aid bubbling trough fluid in drain bottle, rising and falling during respiration
bubbling as swinging reduces as pneumothorax resolves
what are 2 complications of chest drains?
air leaks - around incision site
surgical emphysema
what is the management of recurrent/unresolving pneumothorax?
Video-assisted throascopic surgery - VATS
- Abrasive pleurodesis
- chemical pleurodesis
- pleurectomy
when can people with pneumothoraxes fly?
BTS suggest - 1 week post check X-ray
used to say 6 weeks post pneumothorax
what is one activity that people with pneumothoraxes should never do?
Scuba diving
UNLESS - surgical pleurectomy and normal lung function and chest CT
what are 3 causes of tension pneumothorax?
Trauma
iatrogenic - thoracentesis, NIV
Spontaneous - underlying lung disease
what is the management for a tension pneumothorax?
14G (orange) cannula into 2nd intercostal space midclavicular line - needle throacostomy
OR (ALTS) /5th intercostal space anterior to midaxillary line
High flow O2
what are 5 signs of a tension pneumothorax?
Tracheal deviation - away from pneumothorax
reduced air entry on one side
Hyperressonance of affected side
tachycardia
hypotension
what is the causative agent for TB?
mycobacterium tuberculosis
acid fast bacilli
what staining is used for mycobacterium tuberculosis?
Zeihl-neelson stain
Turns bright red against blue background
what are the 4 possible outcomes of TB?
Clearance - most people
Primary active TB - active infection after exposure
Latent TB
Secondary TB - reactivation of latent TB to active infection
what is the name of disseminated severe TB?
Miliary TB
where is the most common site of TB?
lungs
where are 8 possible locations for extrapulmonary TB?
Lymph nodes
Pleura
CNS
Pericardium
GI system
GU system
Bones and joints
Skin (cutaneous)
what are tuberculoid abscesses like?
‘cold’ abscess - firm painless abscess caused by TB - not hot red and painful like other abscesses
what are 5 risk factors for TB?
birth in endemic country
exposure to infection
immunosuppression
Homelessness
IVDU
what is the pathophysiology of TB?
Inhalation of droplet nuclei => engulfed by alveolar macrophages => Multiplies within alveolar macrophage and burst out causing a response from the immune system => either clearance, latent infection or progression to primary disease
what kind of granuloma is formed in TB?
caseating
what is the lesion in the lungs in TB known as?
Ghon focus
what are 9 presentations of TB?
Cough
fever
anorexia/weight loss
lethargy
night sweats
haemoptysis
Lymphadenopathy
Erythema nodosum
Spial pain - spinal TB
what are 2 investigations for an immune response to TB?
Mantoux test
Interferon-gamma release assay
what is the mantoux test?
For TB (+ve after BCG)
inject tuberculin into intradermal space in forearm, leave for 72 hours and measure - >5mm = +ve
what is the interferon-gamma release assay?
For TB
mix blood sample with TB antigens - interferon gamma will be released if previous TB sensitisation
what can be seen on CXR in TB?
Primary - patchy consolidation, pleural effusions and hilar lymphadenopathy
Secondary - patchy/nodular consolidation, cavitation, typically in upper zones
Disseminated - millet seeds uniformly distributed across lung fields
what investigation can be used in TB to determine genetic material of pathogen that is quicker than culture?
nucleic acid amplification test
what is the gold standard investigation of TB?
sputum culture
what is the treatment for active TB?
RIPE
rifampicin - 6 months
Isoniazid - 6 months
Pyrazinamide - 2 months
Ethambutol - 2 months
what is the treatment of latent TB?
Isoniazid PLUS rifampicin for 3 months
OR
Isoniazid for 6 months
what are 2 side effects of Rifampicin?
Rifam-PISSIN
Red/orange bodily secretions
Cytochrome P450 inducer
what is one key side effect of isoniazid?
Iso-numb-azid
Peipheral neuropathy
what is co-prescribed with isoniazid to reduce side effects?
Pyridoxine B6
what is one key side effect of pyrazinamide?
Hyperuricaemia - gout and kidney stones
what is one key side effect of ethambutol?
E = Eyes!
Colour blindness and reduced visual acuity
what 3 TB medications cause hepatotoxicity?
Rifampicin
Isoniazid
Pyrazinamide
what are 3 complications of TB?
transmission
ARDS
pneumothorax
what do you have to do when someone is diagnosed with TB?
INFORM PUBLIC HEALTH ENGLAND
Isolate patient
what are 5 atypical pneumonia pathogens?
Legions of psittaci MCQs
Legionella pneumophila - air conditioning, water sources, hyponatraemia, deranged LFTs
Chlamydophila psittaci
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Q fever - Coxiella burnetti
How is legionnaire’s disease diagnosed?
Urinary legionella antigen
what is the management of legionnaire’s disease?
Clarithromycin
500mg PO BD 4-14 days
OR
IV 500mg every 12 hours for 5 days
what is one complication of legionnaire’s disease?
SIADH leading to hyponatraemia
what is a presenting feature of mycoplasma pneumoniae pneumonia?
Mild pneumonia
Erythema multiforme rash - target lesions of pink rings with pale centres
can also cause neurological symptoms in young patients
what pathogen in pneumonia is associated with birds?
Chlamyia psittaci
what pneumonia causing pathogen is associated with farmers and cattle?
Coxiella burnetti - causes Q fever
when is S. Aureus normally a causative agent of pneumonia?
HAP
after recent influenza
after being on a ventilator
what are the signs of ephysema?
pink puffers - breathing with pursed lips
barrel chest
flattened diaphragm
what are the signs of chronic bronchitis?
wheeze
crackles or rales
cyanosis - blue bloaters
what is is the name of a focal caseating granuloma in TB shown on X-ray?
Ghon complex
what kind of hypersensitivity reaction in TB?
type 4
what are 4 side effects of rifampicin?
hepatitis
orange bodily fluids
flu like symptoms
impaired contraceptive pill
what are 3 side effects of isoniazid?
hepatitis
peripheral neuropathy - pyridoxine prophylaxis
agranulocytosis
what are 3 side effects of pyrazinamide?
hepatitis
gout
arthralgia and myalgia
what are 2 side effects of ethambutol?
optic neutritis
renal impairment
what bacteria is associated with pneumonia in COPD?
Haemophilus influenzae
what bacteria is associated with pneumonia as a secondary cause or with access or empyema?
s. aureus
what fungus can cause pneumonia in immunosuppressed people - usually with HIV?
pneumocytitis jiroveci
what is the most common opportunistic infection in people with HIV?
penumocytitis jiroveci - AIDS defining illness
what staining identifies pneumocytitis jiroveci?
silver staining - fungi
what is the first line management of pneumocytitis jiroveci?
1 - Co-trimoxazole - trimethoprim/sulfamethoxazole
2 - IV pentamidine - in severe cases
Steroids if hypoxic
when should prophylaxis for pneumocystis jirovecii be given?
if CD4 count <200 or Hx of AIDS defining illness
Give co-trimoxazole
what kind of disease is sarcoidosis?
non-caeseating granulomatous disease of unknown aetiolgy that can affect any organ but primarily affects the lungs and intrathoracic lymph nodes
what are granulomas?
inflammatory nodules full of macrophages
what is the typical sarcoidosis patient?
20-40 or around 60 years
Female
Black ethnic origin
what 8 systems are affected by sarcoidosis?
Skin
Respiratory
Hepatobiliary
Ophthalmic
Cardiac
Renal
Central and peripheral nervous systems
Musculosceletal
Can also have systemic symptoms
what are 2 skin presentation in sarcoidosis?
Erythema nodosum - nodules of inflamed subcutaneous fat on the shins - red/dusky raised, tender painful subcutaneous nodules on both shins
Lupus pernio - raised purple skin lesions often on cheeks and nose
what are 3 presentations of pulmonary sarcoidosis?
Bilateral hilar lymphadenopathy - seen on CXR or CT
Obstructive pattern on spirometry - pulmonary fibrosis/nodules
SOB, Dry cough on exertion, chest discomfort
what are 3 hepatobiliary presentations of sarcoidosis?
Liver nodules
cirrhosis
cholestasis
what are 3 ophthalmic presentations of sarcoidosis?
Uveitis
conjunctivitis
optic neuritis
what are 3 cardiac signs of sarcoidosis?
Bundle branch block
Heart block
Myocardial muscle involvement
what are 3 renal presentations of sarcoidosis?
Kidney stones - due to hypercalcaemia
Nephrocalcinosis
Interstitial nephritis
what are 5 neurological presentations of sarcoidosis?
nodules
pituitary involvement - diabetes insipidus
encephalopathy
facial nerve palsy
mononeuritis multiplex
what are 3 MSK presentations of sarcoidosis?
arthritis
arthralgia
myopathy
what is the classical presentation of sarcoidosis?
Lofgren’s syndrome - triad
erythema nodosum
bilateral hilar lymphadenopathy
Polyarthralgia
what electrolyte imbalance does sarcoidosis cause?
hypercalcaemia
what is the gold standard investigation for sarcoidosis?
US guided biopsy of mediastinal lymph nodes on bronchoscopy
what enzyme is elevated in sarcoidosis?
angiotensin converting enzyme (ACE) - all granulomatous disease
what are 6 differentials for sarcoidosis?
TB
Lymphoma
HIV
Hypersensitivity pneumonitis
Toxoplasmosis
Histoplasmosis
How can bilateral hilar lymphadenopathy be diagnosed in sarcoidosis?
CXR/CT chest
what is the management for sarcoidosis?
Conservative management in mild/asymptomatic
1 - Oral corticosteroids - Prescidolone 20-40mg OD
AND bisphosphonates to protect against bone disease
2 - Methotrexate
Lung transplant may be required in severe disease and progression to pulmonary fibrosis
what proportion of the caucasian population is a carrier for CF?
1 in 25
what value is pulmonary hypertension?
> 20 mmHg at rest
what is pulmonary hypertension?
increased ressitance and pressure in the pulmonary arteries causing strain on R heart
what are group 1 causes of pulmonary hypertension?
idiopathic pulmonary hypertension or connective tissue disease (SLE)
what are group 2 causes of pulmonary hypertension?
L disease
Heart failure
valvular heart disease
HOCM
what are group 3 causes of pulmonary hypertension?
Chronic lung disease - COPD, pulmonary fibrosis
Chronic high altitude or hypoxia
what are group 4 causes of pulmonary hypertension?
pulmonary vascular disease - PE, pulmonary artery obstruction (sickling, tumours)
what are group 5 causes of pulmonary hypertension?
Miscellaneous - sarcoidosis, glycogen storage disease, haematological disorders
what are 6 manifestations of pulmonary hypertension?
SOB
Syncope
Tachycardia
Raised JVP
Hepatomegaly
Peripheral oedema
what ECG changes are seen in pulmonary hypertension?
P pulmonale - peaked P waves
R ventricular hypertrophy - tall R waves in V1/2, deep S waves in V5/6
Right axis deviation
RBBB
what is the gold standard for pulmonary hypertension?
right heart catheterisation - directly measures pulmonary pressures
what is seen on CXR in pulmonary hypertension?
Dilate pulmonary arteries
R ventricular hypertrophy
what is the management of idiopathic pulmonary hypertension?
1 - Calcium channel blockers - nifedipine
Prostaglandins - epoprostenol
Endothelin receptor antagonist - macitentan
Phosphodiesterase-5 inhibitors - sildenafil
what type of sensitivity reaction is hypersensitivity pneumonitis?
type III/IV
what is goodpasture’s syndrome also known as?
Anti-glomerular basement membrane disease
what’s goodpasture syndrome?
Autoimmune disorder which causes IgG antibodies against type IV collagen in glomerular and alveolar basement membranes leading to rapidly progressing glomerulonephritis and pulmonary haemorrhage
what are 8 presentations of goodpasture’s syndrome?
Haemoptysis
Haematuria
Oliguria
Malaise
Lung crackles
hypertension
peripheral oedema
pallor
what are 3 risk factors of goodpastures?
HLA-DR15
Male
smoking
infection may be a trigger
what antibodies are present in goodpasture’s syndrome?
anti-GBM antibodies
what is seen on renal biopsy in goodpasture’s syndrome?
Cresenteric glomerulonephritis or linear deposition of IgG along glomerular capillaries
what is the management of goodpasture’s syndrome?
1 -
Corticosteroids
Cyclophosphamide
Plasma exchange
2 - dialysis
what are 4 complications of goodpasture’s syndrome?
AKI
CKD
resp arrest
Corticosteroids side effects
what are 3 differentials for goodpastures?
wegener’s granulomatosis
SLE
microscopic polyangitis
what is the management of good pastures?
immunosuppressants - corticosteroids, cyclophosphamide
plasmapheresis
dialysis
ventilation
what is c-ANCA a marker for?
Wegener’s granulomatosis
what is Wegener’s granulomatosis?
A multi-system disorder of unknown causes characterised by necrotising granulomatous inflammation and vasculitis of small vessels.
affects resp tract and kidneys and is treated with steroids and immunosuppression
what does pulmonary hypertension look like on CXR?
Enlargement of the pulmonary arteries
Lucent lung fields
Enlarged right atrium
Elevated cardiac apex due to right ventricular hypertrophy
what kind of lung tumour can cause Horners syndrome?
pancoast tumour
what does a pancoast tumour press on to cause Horner’s syndrome?
the sympathetic chain
name an ICS?
budesonide
what is bronchiectasis?
permanent dilation of the bronchi leading to sputum and organism collection resulting in a chronic cough, sputum production and infections
what are 8 causes of bronchiectasis?
Idiopathic
Pneumonia
Whooping cough
TB
Alpha-1-antitrypsin deficiency
Connective tissue disorders
CF
Yellow nail syndrome
what is yellow nail syndrome?
Condition causing yellow fingernails, bronchiectasis and, lymphedema
what are 4 symptoms of bronchiectasis?
SOB
Chronic productive chough
Weight loss
what are 4 signs o/e of bronchiectasis?
Wt loss/cachexia
Finger clubbing
Signs of cor pulmonal - raised JVP, peripheral oedema
Scattered crackles, wheezes and squeaks
what are 2 common infective organisms in bronchiectasis?
Haemophilus influenzae
Pseudomonas aeruginosa
what can be seen on CXR in bronchiectasis?
Tram-track opacities - parallel marking of side view of dilated airways
Ring shadows - dilated airways seen on end
what is the investigation of choice for bronchiectasis?
High es CT thorax
what pattern is seen on spirometry in bronchiectasis?
obstructive - <0.7 FEV1:FVC
what prophylactic Abx are given in bronchiectasis with >3 exacerbations per year?
Azithromycin
colonisation with what bacteria in bronchiectasis can be treated with inhaled colistin?
pseudomonas aeruginosa
what antibiotic is given in pseudomonas aeruginosa pneumonias in bronchiectasis?
Ciprofloxacin
usually extended courses of ABx in bronchiectasis - 7-14 days
what are 4 complications of bronchiectasis?
pneumothorax
empyema
lung abscess
life threatening haemoptysis
what is the most common demographic for sarcoidosis?
black females
what is the name of a leukotriene receptor antagonist?
Montelukast
what are 6 features of well controlled asthma?
no night time symptoms
inhaler used < 3X a week
no breathing difficulties most days
exercise without symptoms
normal lung function test
What are pleural plaques?
Most common manifestation of asbestos related lung disease after a latent period of 20-40 years
benign pleural plaques
usually seen on CT
what is asbestosis?
lung fibrosis due to asbestos exposure, exposure related severity
15-30 year latent period
fibrosis picture
what are 5 features of mesothelioma?
SOB, Wt loss, chest wall pain
CLubbing
painless pleural effusion
20% have pre-existing asbestosis
Hx of asbestos exposure in 85-90%
what investigations are used in mesothelioma?
CXR
chest CT
Pleural tap if effusions for MC+S
Local anaesthetic thoracoscopy
image guided biopsy
what is acute bronchitis?
A chest infection which is usually viral and self limiting (3 week course) and causes inflammation of the trachea and major bronchi leading to sputum production
what are 4 presentations of acute bronchitis?
Cough
sore throat
rhinorrhoea
wheeze
what is the difference between acute bronchitis and pneumonia?
Sputum, wheeze and breathlessness may be absent in acute bronchititis
O/E - no focal chest signs in acute bronchitis other than wheeze. No malaise, myalgia, fever
what is the management of acute bronchitis?
Supportive
consider Abx delayed if CRP 20-100 or immediate >200 - doxycycline or amoxicillin
what is an upper respiratory tract infection (URTI)?
Acute usually viral infection of the upper respiratory tract - nose, sinuses, pharynx or larynx
rhinitis, sinusitis, pharyngitis, laryngitis
what are 4 presentations of URTI?
Sore throat
Nasal discharge
dry cough
headache
tiredness
usually resolves in 7-10 days but can last up to 3 weeks
what are 3 complications of an URTI?
sinusitis
otitis media
secondary bacterial infection
what are 8 risk factors for pulmonary embolism?
Immobility
Recent surgery
Long haul travel
pregnancy
Hormone therapy with oestrogen - HRT, COCP
Malignancy
Polycythaemia
SLE
Thrombophilia
what are 9 presentations of pulmonary embolism?
SOB
Cough
Haemoptysis
Pleuritic chest pain
Hypoxia
Tachycardia
Raised Resp rate
low grade fever
haemodynamic instability
what ECG changes may be present in PE?
sinus tachycardia
ST segment and T wave abnormalities
Right axis deviation
RBBB
S1Q3T3 - S wave in lead 1, Q wave in lead 3, T wave inversion in lead 3)
what scoring system can be used to rule out PE?
Pulmonary embolism rule out criteria - PERC - all -ve = <2% chance of PE
What score is used to predict probability of pulmonary embolism?
Wells score for PE
what are 6 conditions that can cause raised D Dimer?
VTE
Pneumonia
Malignancy
Heart failure
Surgery
Pregnancy
what is the 1st line imaging for pulmonary embolism?
CT pulmonary angiogram
what scan is done for pulmonary embolism for patients with renal impairment or contrast allergy?
ventilation perfusion (VQ) scan
What is usually seen on ABG in pulmonary embolism?
respiratory alkalosis - due to blowing off CO2, also hypoxia
what is the management of massive PE?
Thrombolysis -
Alteplase - 10mg over 1-2mins, then 90mg over 2 hours
Tenecteplase, streptokinase
Unfractioned heparin
what is the acute management of pulmonary embolism in patients with no comorbidities?
Interim anticoagulation if testing not immediately available
1 - Apixaban 10mg BD 7 days PO
OR
Riveroxaban 15mg BD for 21 days
2 - LMWH for 5 days then dabigatran or edoxaban
OR
LMWH and warfarin for 5 days till INR stable then Warfarin alone
Warfarin induction = 10mg for 2 days then 3-9mg maintenance
what is the long term management of pulmonary embolism in patients with no other comorbidities?
1 - Continue DOAC for at least 3 months
Apixaban - 5mg BD
Rivaroxaban - 20mg OD
2 - Continue DOAC/Warfarin for 3 months
Edoxaban 60mg OD (30mg if weight <60kg)
Dabigatran - dose based on age
Warfarin - 3-9mg OD maintenance
what is the management of pulmonary embolism in renal impairment (creatinine clearance <15 ml/min)?
LMWH
Unfractionated heparin
LMWH/UFH then Warfarin
what is the management of pulmonary embolism in active cancer?
DOAC if suitable for 3-6 months
how long is treatment of unprovoked PE for?
6 months
How long is treatment of provoked PE for?
3 months
what are 2 interventions for recurrent pulmonary embolism?
Inferior vena cava filter
Surgical embolectomy 0 if thrombolysis is contraindicated/failed
what is the 1st line anticoagulant in pulmonary embolism in pregnancy?
LMWH
what are 5 genetic conditions that increase risk of pulmonary embolism?
Factor V leiden
Prothrombin gene mutation
Protein C deficiency
Protein S deficiency
Antithrombin
what PE well score means that pulmonary embolism is unlikely?
<4
what PE wells score means that pulmonary embolism is likely?
4+
what is the next step in pulmonary embolism diagnosis if wells is <4
D dimer
what is the next step in PE diagnosis if wells score is >4?
Immediate CTPA
Interim anticoagulation if CTPA is delayed - DOAC or LMWH
what scoring system can be used to assess the severity of PE?
Pulmonary embolism severity index
what are 5 complications of pulmonary embolism?
Cor pulmonale
Pulmonary infarction
Heparin associated thrombocytopaenia
Pleural effusion
Respiratory failure
what are 8 causes of occupational lung disease?
Silica - mining, quarrying, construction, ceramics
Coal
Asbestos
Sulphur dioxide - burning fossil fuels
Nitrogen oxide - welding
Ozone - photocopying, welding
Moulds and fungi
Bacteria and animal proteins
Radiation
what spirometry picture is usually seen in occupational lung disease?
restrictive picture FEV1/FVC >0.7
what lung condition can be caused by inhalation of inorganic dusts?
Pneumoconiosis - accumulation of dust in lungs and the response of bodily tissues to its presence
what is the pathophysiology of pneumoconiosis?
Dust (usually coal) particles are inhaled and reach terminal bronchi where they are ingested by interstitial and alveolar macrophages - over long periods of time the macrophages are no longer able to expel mucus and accumulate in alveoli resulting in immune activation and tissue damage
what are 6 complications of occupational lung disease?
Pulmonary fibrosis
COPD
Lung cancer
Pleural disease
Hypoxaemia
Cor pulmonale
what are 2 radiological features of silicosis?
Upper zone fibrosing lung disease
Egg shell calcification of hilar lymph nodes
what condition does silicosis increase risk of?
Tuberculosis
what is the most common cause of pulmonary fibrosis?
idiopathic pulmonary fibrosis
what are 7 causes of upper zone pulmonary fibrosis?
CHARTS
Coal workers pneumoconiosis
Hypersensitivity pneumonitis (extrinsic allergic alveolitis)
Ankylosing spondylitis
Radiation
Tuberculosis
Silicosis/Sarcoidosis
what are 5 causes of lower zone pulmonary fibrosis?
Idiopathic pulmonary fibrosis
Asbestosis
Drug induced
Connective tissue disorders - SLE
Radiation
what are 5 drugs that can cause pulmonary fibrosis?
Amiodarone
Cytotoxic agents - busulphan, bleomycin
Methotrexate
Nitrofurantoin
Ergot derived dopamine receptor agonists
what are 5 risk factors for idiopathic pulmonary fibrosis?
Older age
Male
Smoking
FHx
Dust exposure - hypersensitivity pneumonitis, occupational exposure
what are 5 presentations of pulmonary fibrosis?
progressive dyspnoea
Dry cough
Malaise
Bibasal fine end-inspiratory crackles
Clubbing
what is seen on imaging in pulmonary fibrosis?
Small irregular opacities - ground glass appearance, progressing to honey combing
May be seen on CXR more likely on CT
what is found on spirometry in pulmonary fibrosis?
FEV1/FVC >0.7
FEV1 = normal/decreased
FVC = decreased
what are 5 other conditions associated with pulmonary fibrosis?
Alpha-1 antitrypsin
RhA
SLE
systemic sclerosis
Sarcoidosis
what is the general management of pulmonary fibrosis?
Removal of underlying cause
LTOT
Stop smoking
physio and pulmonary rehab
pneumococcal and flu vaccine
Advanced care planning
Lung transplant
what are 2 antifibrotic agents that can be used in pulmonary fibrosis?
Pirfendidone
Nintedanib
if FVC 50-80% predicted
what investigation can be used to diagnose hypersensitivity pneumonitis?
Bronchoalveolar lavage on bronchoscopy
What are 4 types of hypersensitivity pneumotitis?
Bird fanciers lung
Farmers lung - mouldy hay spores
Mushroom workers lung
Malt workers lung - reaction to barley mould
what chromosome is CF carried on?
chromosome 7
mutations on what gene causes CF?
Cystic fibrosis transmembrane conductance regulatory gene
what is often the first sign of CF?
meconium ileus - not passing meconium in 24 hours, abdo distention, vomiting
what are 7 causes of clubbing in children?
hereditary
cyanotic heart disease
infective endocarditis
CF
TB
IBD
Liver cirhosis
what is the diagnostic chloride concentration on sweat test for CF?
> 60 mmol/L
which are 2 bacteria which are especially difficult to treat in CF?
pseudomonas aeruginosa
Burkholderia cepacia
what is the management of CF?
multidisciplinary
chest physio
exercise
high calorie diet
CREON tablets - for pancreatic insufficiency
prophylactic flucloxacillin
Tx chest infections
bronchodilators
DNase nebs - help clear secretions
hypertonic saline nebs
vaccinations
what does the CF transmembrane conductance regulatory gene code for?
Chloride channels
what are 3 features of CF?
thick pancreatic and biliary secretions causing blockages
low vllume thick airway secretions
congenital bilateral absence of vas deferens
what is the inheritance of CF?
autosomal recessive
what are 3 key tests for CF?
newborn blood spot test
sweat test - GOLD
genetic testing
what is the diagnostic chloride conc for CF on sweat test?
60 mmol/L
what is treatment for pseudomonas infection in CF?
long termtobramycin nebs
or oral ciprofloxacin
what medication can be used in CF patients who are homozygous for the delta F508 mutation?
Lumacaftor/Ivacaftor (Orkambi)
what is one contraindication to lung transplant in CF?
Chronic infection with burkholderia cepacia
what are 5 GI complications of CF?
Pancreatic insufficiency
Liver disease
meconium ileus
distal intestinal obstruction
GORD
what is asthma COPD overlap syndrome?
persistent airflow limitation witgh both features of asthma and COPD.
Reversibility, eosinophilic bronchial and systemic inflammation and increased response to ICS
more common in smokers/ex-smokers
what is the gold standard test for COVID-19?
RT-PCR
what is an antiviral that can be given in COVID-19?
Remedesivir - for hospital patients requiring O2
what are 3 medications that can be used in the management of COVID?
Antivirals - remdesivir
dexamethasone
immunomodulators - tocilizumab
what are 8 causes of respiratory arrest?
Neuromuscular disorders - leading to weak respiratory muscles
Pulmonary disorders - obstructive or restrictive lung disease leading to severely reduced lung function
CNS disorders - stroke, brain injury, tumours
Metabolic alterans - alkalosis/acidosis
Trauma
Anaphylaxis
Toxic ingestions/inhalations
Infections
how does hypercapnia and acidosis cause CNS depression?
increased CO2 levels causes cerebral vasodilation which increased ICP
Acidosis causes CND functional depression including resp centres
CNS depression reduces responsiveness of respiratory centre leading to decreased respiratory effort
what are 2 respiratory patterns that indicate respiratory arrest?
Agonal breathing - gasping, laboured infrequent, irregular breaths
Absent breathing
what is respiratory failure?
when the respiratory system fails to maintain adequate gas exchange resulting in hypoxia and/or hypercapnia
what is type 1 respiratory failure?
Low paO2 (<8 KPa)
Normal/low paCO2
what is type 2 respiratory failure?
Low/normal O2 (<8 KPa)
High PaCO2 (>6 KPa)
what are 5 causes of type 1 respiratory failure?
Pnemonia
Heart failure
Asthma
PE
High altitude pulmonary oedema
what are 6 causes of type 2 respiratory failure?
opiate toxicity
iatrogenic
neuromuscular disease
reduced chest wall compliance
increased airway resistance - COPD
severe impairment of gas exchange
what is the management of type 1 respiratory failure?
Oxygen
Positive end expiratory pressure - CPAP
Extracorporeal membrane oxygenation (ECMO)
treat cause
what is the management of type 2 respiratory failure?
Oxygen failure
NIV
Invasive mechanical ventilation
treat cause
what are the 3 different types of influenza virus?
A - most virulent and responsible for pandemics
B - co-circulated with A but less severe
C - mild or asymptomatic infection
what is the pathophysiology of influenza infection?
Virus invades and replicates in epithelial cell lining of respiratory tract
localised inflammation and immune reaction causes repiratory symptoms
who gets the influenza vaccine?
> 65 years
healthcare professionals
what management can be given for severe influenza?
antivirals - oral oseltamivir or INH zanamivir
BD for 5 days
who is considered at risk with influenza?
> 64 years
chronci resp/cardiac/renal/liver disease
chronic neurological conditions
Diabetes
immunosuppression
morbid obesity
what type of virus is influenza?
RNA
what are 6 complications of influenza?
otitis media, sinusitis, bronchitis
viral pneumonia
secondary bacterial pneumonia
worsening chronic health conditions
febrile convulsions
encephalitis
how is the influenza vaccine given to children?
nasally
first dose at 2-3 years then annually
what is the difference between the nasal flu vaccine for children and the adult flu vaccine?
children’s is live vaccine
what are 7 contraindications of the children’s flu vaccine?
immunocompromised
<2 years
currently ill
current wheeze
egg allergy
pregnancy/breast feeding
aspirin use
How to determine quality of CXR?
RIPE
Rotation - look at clavicles or anterior rib
Inspiration - 5-7 anterior ribs in midclavicular line, 2 domed hemidiaphragms
Picture - apices to costophrenic angles
Exposure
How do you look at a CXR?
ABCDE
Airway
Breath fields
Cardiac
Diaphragm
Everything else/evils
what are the evil areas to recheck in CXR?
ABCDE again
- Apices
- Bones/tissues
- Cardiac – behind it
- Devices/below diaphragm
- Everything
what needs to be seen on CXR of an NG tube?
Line crossing through carina, crossing diaphragm and ending with tip in stomach
must see tip!
what are the names of lines through areas of consolidation that show that though alveoli are full of gunk, the bronchi are clear indicating pneumonia?
air bronchograms
what are the different categories of DVT wells score?
0 - low risk
1-2 - Moderate risk
>2 - High risk DVT
what are the DVT wells criteria?
Active cancer
Bedridden >3 days/major surgery last 12 weeks
Calf swelling >3mm
Collateral superficial veins
Entire leg swollen
tenderness in Deep vein system
pitting oedema
paralysis, paresis or plaster immobilisation
Prev DVT
Alt diagnosis more likely -2 points
what is the PE wells criteria?
Signs/symptoms DVT
PE most likely
HR >100
Immobilisation 3 days or surgery 12 weeks
Prev PE/DVT
Haemoptysis
Malignancy past 6 months
