Resp Flashcards
What Sx should NOT appear in COPD?
Clubbing
Haemoptysis
Chest pain
If patient presents with these, think lung cancer, pulmonary fibrosis or HF
Describe Type 1 Resp failure
Give an example
↓pO2
+
↓ / normal CO2
e.g. Pulmonary embolism!
Describe Type 2 Resp failure
Give an example
↓pO2
+
↑pCO2
e.g. Hypoventilation
Restrictive Resp Disease failure figures
FEV1/FVC > 0.7
FEV1 & FVC both below 80% of predicted value
Example of restrictive resp failure
Sarcoidosis
Pulmonary fibrosis
Goodpasture’s
Obstructive resp disease figures
FEV1/FVC < 0.7
FEV1 < 0.8
Example of Obstructive resp failure
Asthma
COPD (but copd can be both)
CF
Bronchiectasis
Why is restrictive FEV1/FVC > 0.7 ?
SMALL lung vol
∴ most of breath exhaled in first second of expiration (FEV1)
Pathophysiology Restrictive resp failure
V/Q mismatch
Pathophysiology Obstructive Failure
More mucus
∴ Lumen blockage
∴ Air can’t get out
What is Chronic Obstructive Pulmonary disorder?
Disease state of airflow limitation that is NOT fully reversible
Quick!
Haemoptysis + Haematuria simultaneously!
What is it?
Goodpasture’s disease
Type 1 Resp failure - which is it?
Restrictive
Type 2 Resp failure - which is it?
Obstructive
Typical patient of COPD and how they present
What would instantly make you think of another obstructive disease instead?
Older man
Long pack history
Chronic productive cough
Constantly for 2+ years
Often get chest infections
NO DIURNAL VARIATION
Resp failure =?
HYPOXAEMIA w/ systemic effects
+/- hypercapnea
3 types of COPD
Chronic Bronchitis
Emphysema
Alpha-1 antitrypsin deficiency
Pathophysiology Chronic Bronchitis
- Hypertrophy and hyperplasia of mucous glands (happens in response against cigarette smoke)
- Chronic inflamm cells in bronchial walls causes luminal narrowing
∴ MORE mucus + inflamed bronchi + narrow lumen
Pathophysiology Ephysema
Destruction of elastin layer of the bronchioles/alveoli etc
Causes distal air trapping - (can form Bullae)
Types of emphysema
acinar thing idk what it is look it up
Can be centricinar (resp bronchioles only) - Smokers, v common!
OR panacinar - (resp bronchioles, alveoli, alveoli sacs), AAAT def, severe
COPD in a < 40 year old with no/little smoking history
What is the cause?
COPD - Alpha-1 antitrypsin deficiency
Describe the MRC Dysnpnoea score
1 - SOB on marked exertion
2 - SOB on hills
3 - slows down or stop on flat
4 - exercise tolerance is 100-200 yards on flat
5 - housebound, can’t get dressed without SOB
Chronic Bronchitis is associated with what?
BLUE BLOATER
Chronic purulent cough
Dyspnoea
Cyanosis - BLUE
Obesity
Emphysema is associated with what?
PINK PUFFER
Weight loss
Breathless, pursed lips
Muscle wasting
Pursed lips
Emphysematous - PINK
Maintained pO2
How is A1AT def inherited?
Autosomal codominant
Pathophysiology A1AT def
A1AT degrades neutrophil elastase
∴ deficiency = panacinar emphysema and liver issues
A1AT associations
LIVER ISSUES
don’t forget!
Might present with liver stuff (mild RUQ pain, ↑bilirubin, ↑ALP etc)
Comp Emphysema
Bullae
COPD Big sign in XR
Flattened diaphragm
Hyperinflation of lungs
BARREL CHEST!!
Ix COPD
Pulmonary Function Tests!!
1. ↑ Fraction Expired Nitrous Oxide (FeNO)
2. Spirometry (FEV1:FVC < 0.7)
3. Bronchodilator reversibility test! - SHOULD BE < 12% INCREASE IN FEV1 aka irreversible
XR - Flattened diaphragm, Barrel chest, long heart shadow, bullae
Diffusing capacity of CO across lung (DLCO) - low in COPD, normal in asthma
What is COPD characterised by?
Neutrophilic inflammation
Describe micro? or macro?scopic features of COPD
Lots of inflam, fibrosis and alveolar disruption
LITTLE smooth muscle hypertrophy and basement membrane thickening
Describe the values for the 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)
Tx COPD
Long term management
STOP SMOKING!!!!!!!!!!!!!!!!!!
& vaccines against influenza and pneumococcal
then,
1. SABA - Salbutamol (PRN)
2. SABA + LABA (Salmeterol) + LAMA (Tiotropium)
3. SABA + LABA + LAMA + ICS (prednisolone)
–
IF V SEVERE, Long Term O2 Therapy (15+ hours daily for 3 weeks)
Comps COPD
Cor pulmonale
RHF - bc ↑↑↑Portal HTN
↑ Infection risk
Main pathogens in acute COPD exacerbations
S. Pneumoniae
H. influenzae
Tx COPD
Exacerbations
O2 - TARGET 88-92%
Nebulised Salbutamol + ipratropium bromide
ICS
Abx
What is the O2 sat target for COPD patients?
WHY?
Patients are chronic CO2 retainers
XS O2 = ↑Dead space
∴ ↑ V/Q mismatch
∴ ↑ CO2 retention
RESP ACIDOSIS
Comps COPD exacerbations
↓ QoL
↑ Economic costs
↑ Mortality
↓ Lung function
Sx decline
Indications for hospital admission
(COPD)
Marked increase in Sx intensity
Severe underlying COPD
Onset of new physical signs
Exacerbation doesn’t respond to initial medical Tx
Serious comorbidities
Older age
Freq exacerbations
Insufficient home support
Ix COPD exacerbations
ABG
Chest radiograph
ECG
WBC
What are some indications a COPD patient should be put on LTOT?
Chronic readings of <88% O2 sat
OR
O2 < 90% + HF
What is an important condition when on LTOT?
Why?
MUST STOP SMOKING
Bc you’ll blow up and die
SABA and LABA
What are they?
MOA?
Beta agonists - short acting beta2 agonists and long acting beta2 agonists
↑cAMP ∴ smooth muscle relaxation
SAMA and LAMA
What are they?
MOA?
Muscarinic antagonists - Short acting/Long acting muscarinic antagonists
↑cGMP degradation
∴ smooth muscle relaxation
ICS stands for?
Inhaled corticosteroids
Surgery option for very very severe COPD
Lung vol reduction surgery (LVRS)
Note for treating COPD w ICS
Avoid chronic treatment
bc benefit-to-risk ratio isn’t worth it
What is Asthma?
Chronic REVERSIBLE airway disease
Types of Asthma
Allergic (70%) - IgE (T1HS), EXTRINSIC
Environmental triggers, genetics(?), hygiene hypothesis!
↑ EOSINOPHILS
Non-Allergic (30%) - non-IgE, INTRINSIC
May present later, assoc w/ smoking! §
Triggers for Asthma
Infection
Allergens
Cold weather
Exercise
Drugs - BB, aspirin
What is the atopic triad?
Atopic rhinitis
Asthma
Eczema
What is Asthma characterised by?
REVERSIBLE airway obstruction
Airway hyper-responsiveness
Inflamed bronchioles
Mucus hypersecretion
Pathophysiology Asthma
Over-expression of TH2 cells (lymphocytes) in airways (bc of trigger)
∴ IgE production (mast cell degran) + Eosinophilia
∴ Chronic remodelling and Mucus Hypersecretion !!
Signs / Symptoms Asthma
Dry cough w DIURNAL VARIATION (worse in mornings) and worse during episodes!
Dyspnoea
Tight chest
Bilateral wheeze on ausc!
Usually younger patient!
Describe the wheeze in Asthma
Bilateral
Episodic
Polyphonic
Expiratory
Widespread
What does microscopy of asthma show?
Curshmann spirals
Charcot-Leydig crystals
Describe Mild/Moderate Asthma episode
PEFR > 50%
Resp rate < 25
Pulse < 110
Normal speech
Describe a Severe Asthma episode
PEFR 33-50% predicted
RR ≥ 25
HR ≥ 110
Inability to complete sentences
Describe a Life-threatening asthma episode
PEFR < 33%
SaO2 < 92% or PaO2 < 8kPa
Normal PaCO2
Altered conscious level! Exhaustion, arrhythmia, hypotension, silent chest! cyanosis, poor effort
Ix Asthma Attack
PEFR
Oximetry
ABG
Describe a near-fatal asthma attack
Like patient nearly DIED
the worst it could be
↑PaCO2
Ix Asthma
- FeNO
- Spirometry (Obstructive picture)
- Bronchodilator Reversibility test > 12% - shows reversible!!
Tx Asthma Exacerbations
O SHIT ME
O2
Nebulised SABA
Hydrocortisone (ICS)
Ipratropium Bromide
Theophylline - IV
MgSO4 IV
Escalate care
Tx Asthma
- SABA (PRN)
- ## SABA + ICSBefore progressing, ensure technique and compliance is calm
– - SABA + ICS + LTRA
- SABA + ICS + LABA +/- LTRA
- ↑ ICS dose
What does LTRA stand for?
Give an example
Leukotriene Receptor Antagonist
e.g. Montelukast
Examples of SABA
Salbutamol
Terbutaline
Examples of LABA
Salmeterol
Formoterol
What happens with B2-agonists at high doses?
Not selective
Will act on other receptors (e.g. B1 in heart, B3 in adipose tissue)
SAMA examples
Ipratropium bromide
LAMA examples
Tiotropium bromide
ICS examples
Prednisolone
Beclomethasone
Why should you not give BB to asthmatics?
It causes bronchoconstriction
When do you give SAMA?
(general answer)
In acute exacerbations
Ix Asthma
Pulmonary Function Tests!!
1. ↑ Fraction Expired Nitrous Oxide (FeNO)
2. Spirometry (FEV1:FVC < 0.7)
3. Bronchodilator reversibility test! - SHOULD BE > 12% INCREASE IN FEV1 aka reversible !!!!!!!
If bronchodilator reversibility test improves less than 12% = indicates COPD, NOT asthma
Diffusing capacity of CO across lung (DLCO) - low in COPD, normal in asthma
Quick!
Miosis, Ptosis, Anhidrosis - What is it?
Horner’s syndrome
What is a pancoast tumour?
What can it cause? How does this present?
Resp tumour that compresses T1-L2
Can cause ipsilateral horner’s syndrome
Presents with : Miosis, Ptosis, Anhidrosis!!
What is Pemberton’s sign?
What does it mean?
Raising arms causes facial flushing
Means Superior vena cava obstruction bc compression
RIPE
Length and S/E
Rifampicin - 6 months, Red/bloody urine
Isoniazid - 6 months, perIpheral neuropathy
Pyrazinamide - 2 months, hePatitis & gout & arthralgia
Ethambutol - 2 months, Eye problems (optic neuritis)
HAP Def
Pneumonia acquired at least 48 hours after admission
Atypical pneumonia definition
Cause by atypical organisms, not detectable by gram stain
CAP Organisms
SMH
Streptococcus pneumoniae
Moraxella Caterhalis
Haem. Influenzae
HAP Organisms
Peakkkkkksss
Psuedomonas aeruginosa
E.Coli
Klebsiella
Staphylococcus
Organisms causing pneumonia in immunocomp patients
Pneumocystis jiroveci
Atypical pneumonia organisms
Legionella pneumophilia
Mycoplasma pneumoniae
Chlamydia
Clamydophila pneumoniae
Coxiella burnetti
Water cooler/Air conditioner orgnisms?
Legionella
If HIV patient, which organism caused their pneumoniae?
Pneumocystis jiroveci !!
(fungal)
Define pneumonia
Inflammation of lung parenchyma
Usually due to infection that affects distal airways
Forms inflam exudate
What patients are most inclined to get HAP?
Elderly
Ventilator assisted
Post-op
Extrapulmonary features of Mycoplasma pnemoniae
Erythema Multiforme
Haemolytic anaemia
Encephalitis
Raynaud’s
Bullous myringitis - blisters on tympanic membrane
Extrapulmonary features of Legionella pneomophilia
Diarrhoea
Abnormal LFTs
Hyponatraemia
Myalgia, ↑CK
Interstitial nephritis
Encephalitis
What is Klebsiella pneumoniae assoc with?
Homeless
Alcoholic
Hospital
What is Chlamydophilai psittaci assoc w?
Sick birds - parrots
Poultry workers
What is Coxiella Brunetti assoc w?
Partuent animals - sheep
If in ITU, what organism are patients most likely to be infected with?
Psuedomonas aeruginosa
Haemophilus influenzae
Staph. Aureus (MRSA)
Why is HAP more severe than CAP?
Bc most of the causative organisms are drug resistant
e.g. MRSA
Viral causes Pneumoniae
CMV
H.flu
Name an AIDS defining illness
Pneumocystis Pneumonia
RF Pneumonia
Immuno comp
IVDU
Pre-existing Resp disease
Very young/Old
Pathophysiology Typical Pneumonia
Bacteria invades
Exudate forms INSIDE alveoli lumen Sputum!
Pathophysiology Atypical Pneumonia
Bacteria invades
Exudate forms in interstitium of alveoli
Dry cough
Signs / Symptoms Pneumonia
Productive cough w/ purulent sputum!
Pyrexic
Pleuritic chest pain
Dyspnoea
Confusion in elderly
Dull percussion
↑ Tactile fremitus
Wheezing
Coarse crackles
Bronchial breathing sounds
↑ Vocal resonance
↑ RR + HR
↓BP + O2 sats
If atypical - dry cough + low-grade fever
Ix Pneumonia
CXR - GS!!
Shows consolidation
AIR BRONCHOGRAM - fluid filled alveoli?
FBC
Sputum microscopy, culture, sens + gram stain
Test for TB if clinical features suggest!!
Which causative organism does rusty sputum in pneumonia suggest?
S. pneumoniae
What does the CURB score measure?
Pneumonia risk and how to manage patient
Describe the CURB score
CURB-65
C onfusion
Uraemia > 7 mmol/L
RR > 30
BP systolic ≤ 90 mmHg or diastolic ≤ 60 mmHg
65 years or older
–
1 point for each
0-1 = Low risk, outpatient
2 = inpatient
3 - 5 = Admission, severe!
Tx Pneumonia
CURB-65 SCORE!!
0-1 = Oral amoxicillin for 5days
Doxycycline/Clarithromycin if CI
2 = Dual therapy w/ amoxicillin + clarithromycin for 5 days (IV OR PO)
3-5 = IV co-amoxiclav + clarithromycin
–
EXCEPTION !!! LEGIONELLA
Needs Clarythromycin 1st Line
NOTIFIABLE DISEASE!!
–
Maintain O2 sats > 96% (lower if COPD)
Analgesia - NSAIDs
IV fluids
Comps Pneumonia
Parapneumonic effusion
Epyema
When is Aspiration pneumonia seen?
In patients with stroke, bulbar palsy and Myasthenia Gravis
What is aspiration pneumonia?
Aspiration of gastric contents into lungs
Can be fatal bc gastric acid damages lungs
What is Tuberculosis?
Granulomatous caseating disease cause by Mycobacteria
Cause Cystic Fibrosis
Mutation in CFTR gene
Where are the majority of TB cases found?
Africa
Asia (India, China)
Cause TB
Mycobacteria
Acid Fast Bacilli
–
M. Tuberculosis
M. Bovis - unpasteurised milk
M. Africanum
M. microti
How is TB transferred?
Via inhalation - AIRBORNE
OR drinking unpasteurised milk
How to stain for Mycobacteria?
Ziehl-Neelsen stain
Stains RED / PINK !!
RF TB
Country - TRAVEL!! (e.g. travelled to India)
IVDU
Homeless/Crowded housing
Alcoholic
Prisons
HIV+
Immunosuppression
Pathophysiology TB
- TB bacteria is ingested by alveolar macrophages BUT bacteria resist being killed!
∴ granuloma forms - T cells recruited, surround granuloma. Central part of granuloma undergoes NECROSIS - forms caseating granuloma called 1º GHON FOCUS
- Ghon focus spreads to lymph nodes!
GHON FOCUS + LYMPH NODE SPREAD = GHON COMPLEX - As granuloma grows, form cavity full of TB bacilli - expelled when patient coughs
If TB spreads systemically = miliary TB
But most often, contained within granuloma but stays alive (step 1) = Latent TB
Extrapulmonary manifestations TB
Bone - Pott’s disease, pain/swelling of joints
Abdo - Ascites, abdo lymph nodes, ileal malabsorption
GU - Epidydmitis, feq, dysuria, haematuria
CNS - meningitis + CN palsy
Miliary - tiny granulomata everywhere, CXR - little dots in chest
Lymph node - swelling +/- discharge
Signs / Symptoms TB
NIGHT SWEATS & WEIGHT LOSS
Pyrexia - low grade usually
Anorexia
Malaise
PULMONARY TB
Cough > 3 weeks (bc most other causes resolve after that)
SOB
Chest pain
Haemoptysis
On ausc - crackles
Dullness to percuss
Describe the bacteria causing TB
MYCOBACTERIAL (TB, bovis, africanum, microti)
“Acid fast” bacilli
Slightly curved
Beaded bacilli
Stain for TB bacteria
MYCOBACTERIAL SPECIES
Stain with Ziehl-Neesen stain
STAINS RED/PINK
Why is TB bacteria resistant to gram stain?
Bc high lipid content w/ mycolic acids in cell wall
Ix TB
CXR - consolidation, bilateral hilar lymphadenopathy, ghon focus
Multiple sputum cultures w/ Ziehl-Neesen stain
BIOPSY - caseating granuloma
For latent :
Tuberculin skin test - Mantoux test (if pos, could be active or latent)
Interferon gamma release assay
Where is TB commonly found?
South Asia (India, China, Pakistan)
Sub-saharan Africa
Tx TB & its assoc S/E
RIPE
Rifampicin - *Red urine
Isoniazid - perIpheral neuropathy (∴ give VitB6 alongside)
Pyramidine - heP**atitis
Ethambutol - Eye problems (optic Neuritis)
RI = 2 months
PE = 6 months
What must you remember to do after diagnosing a TB patient?
Report to Public Health England !
Quick!
Chronic illness w/ Fever, weight loss, night sweats
What is it?
Think TB!
But obvs rule out malignancy
What is the most common interstitial lung disease?
Pulmonary fibrosis
Inheritance pattern Cystic Fibrosis
Autosomal recessive
Most Patients with CF also have?
Pancreatic insufficiency
RF CF
FHx
Caucasian
Pathophysiology CF
Mutation in CFTR gene
Causes Cl- transport dysfunction
∴ thick mucus secretion from exocrine glands (lungs, pancreas, skin, gonads)
∴ blockage of secretory glands and impaired mucus clearance!
∴ severe lung disease, recurrent infections, pancreatic insufficiency!
CFTR full name & where is it found?
cystic fibross transmembrane conductance regulator
Long arm of Chromosome 7
Signs / Symptoms CF
Recurrent infections
Salty sweat
Pancreatic insufficiency - poor weight gain, steatorrhoea, DM
Bronchiectasis
Male infertility
Bowel obstruction
Cough
Thick mucus production
Haemoptysis
Wheeze
Fever
Nasal polyps
Clubbing
Spontaneous pneumthorax
MECONIUM ILEUS - first stool gets stuck in intestines
WHY do you get pancreatic insufficiency with CF?
Bc enzymes are not released to digest fat
Why do you get male infertility with CF?
Atrophy of vas deferens and epididymis
Ix CF
GS!! Sweat test!! - shows high chlorine and sodium
Genetic newborn screen - if known CFTR mutation
measures immunoreactive trypsinogen (IRT) at time of neonatal heel prick test
Faecal elastase test - low or negative
CXR - hyperinflation, bronchiectasis
Lung function test - early on, only small airways
later, airflow limitation, hyperinflation,
Tx CF
No Cure!
Conservative - MDT approach, chest physio, no smoking
Pancreatic supplements
High Kcal, high fat diet
Postural drainage
Prophylactic Abx -
Flucloxacillin - S. Aureus
Amoxicillin - H. influenzae
Ciprofloxacin - P. aeruginosa
Comps CF
BRONCHIECTASIS
Recurrent infections
What is Bronchiectasis?
Chronic infection of bronchi and bronchioles which causes permanent dilation of central/mid-sized airways
MC pathogen in Bronchiectasis
And also pathogen indicating worse prognosis
Haemophilus Influenzae = MC
But also bad = Pseudomonas aeruginosa
What bacteria is Pseudomonas Aeruginosa?
(like gram stain etc)
Gram negative, Aerobic, oxidase positive (?) bacteria
Signs / Symptoms Bronchiectasis
Productive cough w/ lots of sputum + Dyspnoea
FOUL SMELLING SPUTUM
Haemoptysis
Wheeze
Chest pain
Clubbing
Recurrent chest infections e.g. Hx of pneumonia
Crackles over affected areas, esp base of lungs
Pathophysiology Bronchiectasis
Chronic inflammation
∴ Irreversible damage to airways
∴ Elastin destruction (lung dilation) and collagen deposition!
∴ Stiff, large airways that are plugged with mucus
(↓mucus clearance ∴ recurrent infections)
Causes Bronchiectasis
OBSTRUCTION -
Foreign body e.g. peanut!
Post TB stenosis
Tumour
Thick mucus - CF!
POST-INFECTION -
P. aeruginosa
TB
Measles
Pneumonia
Pertussis
Immunodeficiency
Congenital - Immotile cilia, Chronic sinusitis, Kartagener’s syndrome
Ix Bronchiectasis
CXR - Signet ring sign, Kerley B lines
Bronchioles dilated and appear thicker than adjacent pulmonary artery
Sputum - H. influenzae MC but others too!
GS!!!! HIGH RES CT - Thickened, dilated bronchi w cysts at end of bronchioles
Airways larger than assoc blood vessel!!!
Spirometry - FEV1/FVC < 0.7 (Obstructive)
Tx Bronchiectasis
Chest physio
Stop smoking
Bronchodilators - SABA
Anti-inflamm - azithromycin (↓exacerbations)
Prophylactic Abx
Pseudomonas aeruginosa Abx
Ciprofloxacin
What type of HS reaction is Hypersensitivity Pneumonitis?
Type 3 !!
RF Hypersensitivity Pneumonitis
Occupation!!! e.g. farming
KEEPING BIRDS
Regular use of hot tubs
Pathophysiology Hypersensitivity Pneumonitis
Type 3 HS reaction after exposure to inhaled allergen
∴ causes alveolar and bronchial inflammation
Signs / Symptoms Hypersensitivity Pneumonitis
Types Hypersensitivity Pneumonitis
Farmer’s lung (mouldy hay!) - MC
Pigeon fancier’s lung (avian proteins in bird droppings)
Cheeseworker’s lung - mouldy cheese (aspergillus umbrosus)
Humidifier fever - contam A/C or humidifiers in factories ESP PRINTING WORKS
Maltworker’s lung - mouldy malt
Tx Hypersensitivity Pneumonitis
Remove allergen!!
Use steroids if severe
Ix Hypersensitivity Pneumonitis
History!!!!!!!!!!!!
Usually diagnosed w history and examination
CXR - patchy, nodular infiltrates
Fibrosis if fibrotic HP
What is Sarcoidosis characterised by?
Non-caseating granulomas throughout the body!
What is Sarcoidosis?
Idiopathic multi-system granulomatous disease w lung involvement in 90% of cases
RF Sarcoidosis
African american!!
Females
20-40s
FHx
Prior infection w Mycobacterium Tuberculosis
How is sarcoidosis often found?
Incidentally on routine XR
What is the typical patient of Sarcoidosis?
20 - 40 year old Afro-Caribbean woman
Signs / Symptoms Sarcoidosis
Bilateral Hilar Lymphadenopathy
Dry cough
Dyspnoea
Malaise
Fever
Swollen lymph nodes
Anterior uveitis
Kidney stones
Bone pain
Erythema nodosum
Lupus pernio - blue/red nodules on nose/cheek
Signs / Symptoms Lofgren’s syndrome
TRIAD OF :
1. Erythema Nodosum
2. Bilateral hilar lymphadenopathy
3. Acute polyarthritis (MC = ankles)
What is Lofgren’s syndrome?
Subset of sarcoidosis
Ix Sarcoidosis
Bloods - ↑ACE and ↑ Ca+
CXR! - bilateral hilar lymphadenopathy & pulmonary infiltrates
STAGING
GS!!!!! BIOPSY - shows non-caseating granuloma
Why is there hypercalcaemia in Sarcoidosis?
Bc XS vit D produced by macrophages
Describe the staging for Sarcoidosis
CXR
Stage 0 - no changes
1 - bilateral hilar lymphadenopathy
2 - 1 + diffuse interstitial disease
3 - ONLY interstitial disease (reticulonodular pattern)
4 - Pulmonary fibrosis (honeycombing)
Tx Sarcoidosis
If early stages, can self resolve!
∴ No treatment for stage 1 and asymptomatic stage 2/3
Steroids! - prednisolone
If req or involving lung function, heart, eye, CNS, kidney or persistent infiltrates
Transplant if very severe
Define Pulmonary HTN
mPAP > 25 mmHg
What is mPAP?
Mean arterial pulmonary arterial pressure
Define mild, moderate and severe Pulmonary HTN
mPAP =
Mild 25-40
Mod 40 - 55
Severe 55+
mmHg
Causes Pulmonary HTN
Pre-Capillary : 1º pul htn, pul emboli!
Capillary : COPD, asthma
Post-Capillary : LV failure
Chronic hypoxaemia - COPD, high altitude
Pathophysiology Pul HTN
Hypoxaemia causes reactive pulmonary vasoconstriction
bc body thinks this is dead space!!
∴ RVH and resp failure
How is mPAP measured?
w/ Right heart catheterisation
Signs / Symptoms Pul HTN
Exertional dyspnoea
Fatigue
RH failure signs ! - ↑JV, periph oedema, loud S2
Ix Pul HTN
CXR - RVH
ECG - RA dilation - peaked P waves > 2.5mm
Echo - RVH
**GS!!!!!* right heart catheter (>25mmHg)
Tx Pul HTN
Phosphodiesterase-5-inhibitor aka Sildenafil aka VIAGRA
CCB - amlodopine
Endothelin-1-antagonist e.g. bosentan
Diuretics - oedema
Comps Pul HTN
COR PULMONALE
Prevention Pneumonia
Polysaccharide pneumococcal vaccine
Types of Pleural Effusion
TRANSUDATIVE - due to ↑hydrostatic pressure or oncotic pressure
LOW PROTEIN COUNT < 25g/L
TRANSPARENT
EXUDATIVE - due to inflammation
HIGH PROTEIN COUNT > 35g/L
CLOUDY
Causes Transudative pleural effusion
↑BP or low protein count
e.g. Congestive HF, fluid overload, Hypoalbuminaemia (liver cirrhosis, nephrotic), constrictive pericarditis
Causes Exudative Pleural effusion
Inflammation causing ↑ vascular permeability
e.g. pneumonia, lung cancer, TB, SLE
Signs / Symptoms Pleural effusion
Stony dull percussion on ipsilateral side
↓ Breath sounds
Dyspnoea
Trachea deviation AWAY from effusion - if large effusion
Cough
Pleuritic chest pain
↓ Tactile fremitus
Ix Pleural effusion
GS! - CXR! (also 1st Line)
↓Costophrenic angle - ‘blunting’
XS fluid appears WHITE
+/- tracheal deviation away from effusion
Transudate - bilateral (TB)
Exudate - unilateral (EU)
–
Thoracentesis - sample pleural fluid to check transudate or exudate
Also : pH, lactate, WBC, microscopy
What is tactile fremitus?
Why is it decreased w pleural effusion?
Vibration that occurs when we speak
Bc effusion absorbs some of the vibrations
Tx Pleural effusion
Tx underlying cause
Drain if symptomatic
(Exudate usually drained, transudate usually managed by treating underlying symptoms)
Pleurodesis - injection that causes adhesion of visceral and parietal pleura, helps prevent reaccumulation of effusion
e.g. tetracycline
Surgery - pleurectomy
Patients with a spontaneous pneumothorax often tend to be?
Tall and thin young males
Might have connective tissue disorder - Marfan’s/ED +/- a smoker / trauma
When in a lifetime does spontaneous pneumothorax often occur?
Between 20 - 40 years old
Types of pneumothorax
Spontaneous
Traumatic
Iatrogenic
Lung pathology
Tension! - emergency
What is a pneumothoax?
Air in the pleural space
Causes lungs to collapse
Signs / Symptoms Pneumothorax
Dyspnoea
One sided sharp pleuritic chest pain
↓ Breathing sounds
HYPERRESONANT percussion ipsilaterally
↓ Tactile fremitus
↓ Chest expansion
As pneumothorax enlarges, Px is more breathless. May develop pallor and tachycardia
One big difference between Pneumothorax and Pleural effusion
Pneumothorax has :
Hyperresonant percussion ipsilaterally
while pleural effusion has:
Stony dull percussion ipsilaterally
Causes Pneumothorax
1º - Simple :
Spontaneous rupture of pleural bleb at apex of lung into pleural space
2º- Complicated :
Trauma! - esp iatrogenic e.g. post thoracentesis, mechanical ventilation, CVP lines
Rupture of subpleural bleb - COPD
Necrosis of lung tissue - pneumonia, abscess, lung carcinoma
Catamenial pneumothorax - during menstruation
Tension - 1 way valve of air entering
RF Pneumothorax
Male
Tall & thin
Smoking
Age
Mechanical ventilation
DDx Pneumothorax
Pleural effusion
PE
Ix Pneumothorax
CXR - GS!!!!
Absent lung markings
Tracheal deviation to OTHER side
Affected area - much darker
ABG
CT is more sens, do for small pneumothorax
Tx CXR
If asymptomatic, self-healing
If symptomatic, needle aspiration (2nd ICS)
OR chest drain (more long term Tx)
Recurrent - pleurodesis (surgery)
What is tension pneumothorax?
MEDICAL EMERGENCY
Pathophysiology Tension Pneumothorax
One way valve mechanism!
Air can flow into pleural space BUT CANNOT LEAVE
∴ With every breath, intrapleural pressure ↑ !!
(Puts pressure on heart, causes cardiac Sx)
Signs / Symptoms Tension Pneumothorax
Cardiopulmonary deterioration! - Hypotension, Resp distress, ↓ Sats, Tachycardia, Shock
Severe chest pain
Tx Tension Pneumothorax
!!!!
Insert large bore cannula into 2nd ICS @ midclav line
Needle decompress first
THEN chest drain
!!!!
Ix Tension Pneumothorax
Usually obvious
Go straight to Tx !!!
What is Otitis media?
Inflamed middle ear
usually in children
Causes Otitis Media
Bacterial - Streptococci
or viral
Ix Otitis Media
Otoscopy shows inflamed erythematous tympanic membrane
What is sinusitis?
Inflamed mucosa of nasal cavity & nasal sinuses
Causes Sinusitis
Mostly viral (< 10 days, non-purulent discharge)
Bacterial (> 10 days, purulent discharge) - S. pneumo, H. influenzae
What are Sinusitis and Otitis Media assoc with?
Meningitis!!
Contiguous spread - directly to meninges
Tx Bacterial Sinusitis
Amoxicillin
Where do emboli of PE usually arise from?
From thrombi in iliofemoral veins - DVT
RF PE
Change in blood flow - Immobility, Obesity, pregnancy
Change in blood vessels - smoking, HTN
Change in blood constituents - Dehydration, malignancy, COCP, Polycythaemia, nephrotic
Recent surgery
FHx
Past history of thromboembolism
Signs / Symptoms PE
Sudden onset SOB
Pleuritic chest pain
Haemoptysis
Hypotension
Tachypnoea
Pleural rub
Pleural effusion
tachycardia
↑ JVP
Ix PE
CXR- often normal
Bloods - ↑ troponin
CT PUL ANGIOGRAPHY - GS!!!!
ECG - Can be normal
RBBB
RA dilation - tall peaked P in lead II
RV strain - inverted T wave in V1-V4
ABG - might be normal but can show Type 1 resp failure
Tx PE
LMWH e.g. enoxaparin or dalteparin initially
then warfarin once confirmed
In whom is idiopathic pulmonary fibrosis found in?
Older men (60+) who smoke
RFs Idiopathic pul fibrosis
Smoking
Occupation e.g. dust
Drugs - methotrexate
Viruses - EBV, CMV
Pathophysiology Idiopathic pul fibrosis
Progressive scarring leading to Type 1 resp failure
No known cause
Ix Idiopathic Pul Fibrosis
Spirometry = FEV1/FVC > 0.7 but FVC is low < 0.8
aka Restrictive picture
**GS!!!* HIGH RES CT = GROUND GLASS APPEARANCE OF LUNGS
Signs / Symptoms Idiopathic pul fibrosis
Exertional dyspnoea
Dry cough
Tx Idiopathic Pulmonary fibrosis
Stop smoking + vaccines
Pirfenidone, nintedanib
Lung transplant - last resort!
What is Hypersensitivity Pneumonitis aka?
Extrinsic Allergic Alveolitis
Mouldy hay antigen
Micropolyspora faeni
Mould on grape antigen
Botrytis
What is SARS?
Severe Acute resp syndrome - emergency resp infection!
Assoc w coronavirus
Outbreak from China
Resp failure
Where is Avian flu seen?
SE Asian
Signs / Symptoms Sinusitis
Frontal headache
Facial pain
Fever
Purulent nasal discharge
Tenderness
What is Acute Epiglottitis?
Usually in children < 5 years but also in adults!
Inflam of epiglottis
Rare now bc Hib vaccine
What is the epiglottis?
Flap of cartilage behind root of tongue
Causes Epliglottitis
H. inflenzae type B (Hib)
Causes of pharyngtitis and other bacterial infections of airway
Signs / Symptoms Epiglottitis
Sore throat
Odynophagia
High pitched wheeze - insp stridor
Diarrhoea
Fatigue
Weight loss
Severe airflow obstruction
Meningitis
Septic arthritis
Osteomyelitis
Tx Epiglottitis
IV ABx - Amoxicillin, Co-amoxiclav etc
Endotracheal intubation
Causes Whooping Cough
Bordatella pertussis
Describe Bordatella pertussis
In terms of gram stain etc
Gram neg, aerobic coccobacillus (ROD)
Signs / Symptoms Whooping Cough
Chronic cough
Classic insp whoop
Vomiting
Malaise
Anorexia
Rhinorrhoea
Tx Whooping Cough
Antimicrobials - clarithromycin
Vaccination
Signs / Symptoms Croup
Prominent barking cough
Febrile
Resp rate = 40
Cyanosis
Insp stridor
Hoarse throat
Cause Silicosis
Inhalation of sillicon dioxide
Ix Silicosis
EGGSHELL calcification of hilar lymph nodes
What is Asbestosis?
Inhalation of asbestos
Affects pleura
Ix Asbestosis
Type 1 resp failure picture
Microscopy - ferruginous bodies (yellow/brown rod shaped)
CLUBBING MORE LIKELY THAN IN SILICOSIS
Name the types of Pneumoconiosis
Asbestosis
Silicosis
What’s the most common ILD?
Idiopathic pul fibrosis
Name the drugs that induce Interstitial lung disease
Bleomycin - Hodgkin’s!
Amiodarone
Nitrofurantoin
Connective tissue IDL types
Scleroderma
RA
RF Pneumoconiosis
Electrician
Joiner
Plumber
Typically worked around 1980s
Types of Lung cancers
(that i care about)
Pleural - Mesothelioma
Bronchial - Small cell & then squamous, adenocarcinoma
1º Metastasis sites Lung cancers
Bone
Liver
Adrenals - usually ASx
Brain
Lymph nodes
Cause Mesothelioma
ASBESTOS !! - usually don’t present until decades after exposure
Pleural or Broncial Carcinoma - MC?
BRONCHIAL
Cancer with smoking assoc?
SMALL CELL LUNG CANCER
TNM Classification Lung Cancer
TUMOUR
T1 - < 3cm
T2 - >3cm
T3 - invades chest wall, diaphragm, pericardium
T4 - invades mediastinum, heart, great vessels, trachea, oesophagus, vertebra, carina
NODES
N0 - none
N1 - Hilar nodes
N2 - Same side mediastinal or subcarinal
N3 - Contralateral mediastinal OR supraclavicular
METASTASES
M0 - none
M1a - Tumour on same side
M1b - tumour elsewhere
X - unknown
Other than pleura, sites of mesothelial cancer please
Mesothelial cells of :
Peritoneum
Pericardium
Testes
Signs / Symptoms Mesothelioma
Cancer Sx - weight loss, night sweats etc
SOB
Persistent cough
Pleuritic chest pain
Haemoptysis
Tumour might press on nearby structures - recurrent laryngeal ∴ hoarse voice
Also sign of mets - bone pain
Ix Mesothelioma
1st Line - CXR, then CT
Will see pleural thickening +/- effusion
(CT higher res, more detail than CXR)
GS!!! - BIOPSY
↑ CA-125 - cancer antigen 125
Non spec raised in lots of tumours
∴ sens not specific!
Tx Mesothelioma
Palliative :(
If found early, might do surgery/chemo etc
But usually resistant :(
V aggressive tumour, avg survival ~ 1 year
Why doesn’t Mesothelioma distantly mets?
Bc affects pleura
Pleura isn’t found everywhere in the body
Who does SCLC affect?
Exclusively smokers!!!
What Paraneoplastic syndromes can SCLC cause?
Ectopic ACTH - Cushing’s
Ectopic ADH - SIADH
Lambert Eaton syndrome
Describe SCLC
Fast growing
Early mets
What is Small Cell Lung Cancer?
Malignancy affecting central resp system - bronchi!
Signs / Symptoms SCLC
Cancer B Sx
Compression Sx
Cough
Haemoptysis
SOB
Recurrent chest pain
Mets early ∴ Mets Sx - bone pain
List Bronchial Carcinomas in order of MC to LC
Adenocarcinoma
SCC
SCLC
Ix SCLC
1st Line - CXR, then CT
**GS!!!!* - BRONCHOSCOPY + BIOPSY
Appears as small cells w minimal cytoplasm
Staging
Tx SCLC
If caught early, try chemo/radio
Usually palliative :(
What is Adenocarcinoma?
Bronchial carcinoma arising from mucus secreting glandular epithelium!!
RF Adenocarcinoma
ASBESTOS
Where does Adenocarcinoma affect?
Peripheral lung but can be central
Signs / Symptoms Adenocarcinoma
Cancer B Sx
Compression Sx
Cough
Haemoptysis
SOB
Recurrent chest pain
Mets common! - pleura, lymph nodes, brain, bone, adrenal glands
Assoc w/ HYPERTROPHIC PULMONARY OSTEOARTHROPATHY
Triad : 1. Clubbing 2. Arthritis 3. Long bone swelling
Ix Adenocarcinoma
1st Line - CXR, then CT
GS!!! BRONCHOSCOPY + BIOPSY
TNM STAGING
Tx Adenocarcinoma
Relatively treatable! :)
Chemo +/- radiotherapy
Surgical excision sometimes
Paraneoplastic Syndrome of Squamous Cell Carcinoma
PTHrP
∴ Hypercalcaemia
Describe the mets of Squamous Cell carcinoma
Mets late
Spreads locally usually
What is Squamous Cell Carcinoma?
Bronchial carcinoma arising from lung epithelium that resembles SQUAMOUS epithelium!
Assoc of NSCLC
(Both SCC and Adenocarcinoma)
HYPERTROPHIC PULMONARY OSTEOARTHROPATHY
Triad :
1. Clubbing
2. Arthritis
3. Long bone swelling
Who does Squamous cell carcinoma affect?
Smokers!
More than any other NON-SCLC
Signs / Symptoms SCC
Cancer B Sx
Compression Sx
Cough
Haemoptysis
SOB
Recurrent chest pain
Ix SCC
1st Line - CXR, then CT
GS!!! BRONCHOSCOPY + BIOPSY
TNM STAGING
Tx SCC
Usually surgical excision !
If mets - chemo/radio
Characteristics of Pneumocystitis Jiroveci pneumonia
Less productive cough than in typical pneumonia
Exercise induced desaturation
Relative lack of other clinical signs (e.g. chest clear on auscultation)
