Resp Flashcards

1
Q

What Sx should NOT appear in COPD?

A

Clubbing
Haemoptysis
Chest pain

If patient presents with these, think lung cancer, pulmonary fibrosis or HF

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2
Q

Describe Type 1 Resp failure
Give an example

A

↓pO2
+
↓ / normal CO2

e.g. Pulmonary embolism!

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3
Q

Describe Type 2 Resp failure
Give an example

A

↓pO2
+
↑pCO2

e.g. Hypoventilation

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4
Q

Restrictive Resp Disease failure figures

A

FEV1/FVC > 0.7
FEV1 & FVC both below 80% of predicted value

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5
Q

Example of restrictive resp failure

A

Sarcoidosis
Pulmonary fibrosis
Goodpasture’s

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6
Q

Obstructive resp disease figures

A

FEV1/FVC < 0.7
FEV1 < 0.8

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7
Q

Example of Obstructive resp failure

A

Asthma
COPD (but copd can be both)
CF
Bronchiectasis

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8
Q

Why is restrictive FEV1/FVC > 0.7 ?

A

SMALL lung vol
∴ most of breath exhaled in first second of expiration (FEV1)

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9
Q

Pathophysiology Restrictive resp failure

A

V/Q mismatch

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10
Q

Pathophysiology Obstructive Failure

A

More mucus
∴ Lumen blockage
∴ Air can’t get out

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11
Q

What is Chronic Obstructive Pulmonary disorder?

A

Disease state of airflow limitation that is NOT fully reversible

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12
Q

Quick!
Haemoptysis + Haematuria simultaneously!
What is it?

A

Goodpasture’s disease

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13
Q

Type 1 Resp failure - which is it?

A

Restrictive

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14
Q

Type 2 Resp failure - which is it?

A

Obstructive

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15
Q

Typical patient of COPD and how they present

What would instantly make you think of another obstructive disease instead?

A

Older man
Long pack history
Chronic productive cough
Constantly for 2+ years
Often get chest infections

NO DIURNAL VARIATION

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16
Q

Resp failure =?

A

HYPOXAEMIA w/ systemic effects
+/- hypercapnea

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17
Q

3 types of COPD

A

Chronic Bronchitis
Emphysema
Alpha-1 antitrypsin deficiency

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18
Q

Pathophysiology Chronic Bronchitis

A
  1. Hypertrophy and hyperplasia of mucous glands (happens in response against cigarette smoke)
  2. Chronic inflamm cells in bronchial walls causes luminal narrowing

∴ MORE mucus + inflamed bronchi + narrow lumen

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19
Q

Pathophysiology Ephysema

A

Destruction of elastin layer of the bronchioles/alveoli etc
Causes distal air trapping - (can form Bullae)

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20
Q

Types of emphysema
acinar thing idk what it is look it up

A

Can be centricinar (resp bronchioles only) - Smokers, v common!
OR panacinar - (resp bronchioles, alveoli, alveoli sacs), AAAT def, severe

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21
Q

COPD in a < 40 year old with no/little smoking history
What is the cause?

A

COPD - Alpha-1 antitrypsin deficiency

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22
Q

Describe the MRC Dysnpnoea score

A

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

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23
Q

Chronic Bronchitis is associated with what?

A

BLUE BLOATER
Chronic purulent cough
Dyspnoea
Cyanosis - BLUE
Obesity

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24
Q

Emphysema is associated with what?

A

PINK PUFFER
Weight loss
Breathless, pursed lips
Muscle wasting
Pursed lips
Emphysematous - PINK
Maintained pO2

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25
How is A1AT def inherited?
Autosomal codominant
26
Pathophysiology A1AT def
A1AT degrades neutrophil elastase ∴ deficiency = panacinar emphysema and liver issues
27
A1AT associations
LIVER ISSUES don't forget! Might present with liver stuff (mild RUQ pain, ↑bilirubin, ↑ALP etc)
28
Comp Emphysema
Bullae
29
COPD Big sign in XR
Flattened diaphragm Hyperinflation of lungs BARREL CHEST!!
30
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 If bronchodilator reversibility test improves more than 12% = indicates asthma, NOT COPD -- XR - Flattened diaphragm, Barrel chest, long heart shadow, bullae Diffusing capacity of CO across lung (DLCO) - low in COPD, normal in asthma
31
What is COPD characterised by?
Neutrophilic inflammation
32
Describe micro? or macro?scopic features of COPD
Lots of inflam, fibrosis and alveolar disruption LITTLE smooth muscle hypertrophy and basement membrane thickening
33
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)
34
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)
35
Comps COPD
Cor pulmonale RHF - bc ↑↑↑Portal HTN ↑ Infection risk
36
Main pathogens in acute COPD exacerbations
S. Pneumoniae H. influenzae
37
Tx COPD Exacerbations
O2 - TARGET 88-92% Nebulised Salbutamol + ipratropium bromide ICS Abx
38
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
39
Comps COPD exacerbations
↓ QoL ↑ Economic costs ↑ Mortality ↓ Lung function Sx decline
40
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
41
Ix COPD exacerbations
ABG Chest radiograph ECG WBC
42
What are some indications a COPD patient should be put on LTOT?
Chronic readings of <88% O2 sat OR O2 < 90% + HF
43
What is an important condition when on LTOT? Why?
MUST STOP SMOKING Bc you'll blow up and die
44
SABA and LABA What are they? MOA?
**Beta agonists** - short acting beta2 agonists and long acting beta2 agonists ↑cAMP ∴ smooth muscle relaxation
45
SAMA and LAMA What are they? MOA?
**Muscarinic antagonists** - Short acting/Long acting muscarinic antagonists ↑cGMP degradation ∴ smooth muscle relaxation
46
ICS stands for?
Inhaled corticosteroids
47
Surgery option for very very severe COPD
Lung vol reduction surgery (LVRS)
48
Note for treating COPD w ICS
Avoid chronic treatment bc benefit-to-risk ratio isn't worth it
49
What is Asthma?
Chronic REVERSIBLE airway disease
50
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! §
51
Triggers for Asthma
Infection Allergens Cold weather Exercise Drugs - BB, aspirin
52
What is the atopic triad?
Atopic rhinitis Asthma Eczema
53
What is Asthma characterised by?
REVERSIBLE airway obstruction Airway hyper-responsiveness Inflamed bronchioles Mucus hypersecretion
54
Pathophysiology Asthma
Over-expression of TH2 cells (lymphocytes) in airways (bc of trigger) ∴ IgE production (mast cell degran) **+** Eosinophilia ∴ Chronic remodelling and Mucus Hypersecretion !!
55
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!
56
Describe the wheeze in Asthma
Bilateral Episodic Polyphonic Expiratory Widespread
57
What does microscopy of asthma show?
Curshmann spirals Charcot-Leydig crystals
58
Describe Mild/Moderate Asthma episode
PEFR > 50% Resp rate < 25 Pulse < 110 Normal speech
59
Describe a Severe Asthma episode
PEFR 33-50% predicted RR ≥ 25 HR ≥ 110 Inability to complete sentences
60
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
61
Ix Asthma Attack
PEFR Oximetry ABG
62
Describe a near-fatal asthma attack | Like patient nearly DIED the worst it could be
↑PaCO2
63
Ix Asthma
1. FeNO 2. Spirometry (Obstructive picture) 3. Bronchodilator Reversibility test > 12% - shows reversible!!
64
Tx Asthma Exacerbations
**O SHIT ME** **O**2 Nebulised **S**ABA **H**ydrocortisone (ICS) **I**pratropium Bromide **T**heophylline - IV **M**gSO4 IV **E**scalate care
65
Tx Asthma
1. SABA (PRN) 2. SABA + ICS -- Before progressing, ensure technique and compliance is calm -- 3. SABA + ICS + LTRA 4. SABA + ICS + LABA +/- LTRA 5. ↑ ICS dose
66
What does LTRA stand for? Give an example
Leukotriene Receptor Antagonist e.g. Montelukast
67
Examples of SABA
Salbutamol Terbutaline
68
Examples of LABA
Salmeterol Formoterol
69
What happens with B2-agonists at high doses?
Not selective Will act on other receptors (e.g. B1 in heart, B3 in adipose tissue)
70
SAMA examples
Ipratropium bromide
71
LAMA examples
Tiotropium bromide
72
ICS examples
Prednisolone Beclomethasone
73
Why should you not give BB to asthmatics?
It causes bronchoconstriction
74
When do you give SAMA? (general answer)
In acute exacerbations
75
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
76
Quick! Miosis, Ptosis, Anhidrosis - What is it?
Horner's syndrome
77
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!!
78
What is Pemberton's sign? What does it mean?
Raising arms causes facial flushing Means Superior vena cava obstruction bc compression
79
RIPE Length and S/E
**R**ifampicin - 6 months, **R**ed/bloody urine **I**soniazid - 6 months, per**I**pheral neuropathy **P**yrazinamide - 2 months, he**P**atitis & gout & arthralgia **E**thambutol - 2 months, **E**ye problems (optic neuritis)
80
HAP Def
Pneumonia acquired at least 48 hours after admission
81
Atypical pneumonia definition
Cause by atypical organisms, not detectable by gram stain
82
CAP Organisms
**SMH** Streptococcus pneumoniae Moraxella Caterhalis Haem. Influenzae
83
HAP Organisms
Peakkkkkksss **P**suedomonas aeruginosa **E**.Coli **K**lebsiella **S**taphylococcus
84
Organisms causing pneumonia in immunocomp patients
Pneumocystis jiroveci
85
Atypical pneumonia organisms
Legionella pneumophilia Mycoplasma pneumoniae Chlamydia Clamydophila pneumoniae Coxiella burnetti
86
Water cooler/Air conditioner orgnisms?
Legionella
87
If HIV patient, which organism caused their pneumoniae?
Pneumocystis jiroveci !! (fungal)
88
Define pneumonia
Inflammation of lung parenchyma Usually due to infection that affects distal airways Forms inflam exudate
89
What patients are most inclined to get HAP?
Elderly Ventilator assisted Post-op
90
Extrapulmonary features of Mycoplasma pnemoniae
**Erythema Multiforme** Haemolytic anaemia Encephalitis Raynaud's Bullous myringitis - blisters on tympanic membrane
91
Extrapulmonary features of Legionella pneomophilia
Diarrhoea Abnormal LFTs Hyponatraemia Myalgia, ↑CK Interstitial nephritis Encephalitis
92
What is Klebsiella pneumoniae assoc with?
Homeless Alcoholic Hospital
93
What is Chlamydophilai psittaci assoc w?
Sick birds - parrots Poultry workers
94
What is Coxiella Brunetti assoc w?
Partuent animals - sheep
95
If in ITU, what organism are patients most likely to be infected with?
Psuedomonas aeruginosa Haemophilus influenzae Staph. Aureus (MRSA)
96
Why is HAP more severe than CAP?
Bc most of the causative organisms are drug resistant e.g. MRSA
97
Viral causes Pneumoniae
CMV H.flu
98
Name an AIDS defining illness
Pneumocystis Pneumonia
99
RF Pneumonia
Immuno comp IVDU Pre-existing Resp disease Very young/Old
100
Pathophysiology Typical Pneumonia
Bacteria invades Exudate forms INSIDE alveoli lumen Sputum!
101
Pathophysiology Atypical Pneumonia
Bacteria invades Exudate forms in interstitium of alveoli Dry cough
102
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
103
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!!
104
Which causative organism does rusty sputum in pneumonia suggest?
S. pneumoniae
105
What does the CURB score measure?
Pneumonia risk and how to manage patient
106
Describe the CURB score
**CURB-65** **C** onfusion **U**raemia > 7 mmol/L **R**R > 30 **B**P 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!
107
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
108
Comps Pneumonia
Parapneumonic effusion Epyema
109
When is Aspiration pneumonia seen?
In patients with stroke, bulbar palsy and Myasthenia Gravis
110
What is aspiration pneumonia?
Aspiration of gastric contents into lungs Can be fatal bc gastric acid damages lungs
111
What is Tuberculosis?
Granulomatous caseating disease cause by Mycobacteria
112
Cause Cystic Fibrosis
Mutation in CFTR gene
113
Where are the majority of TB cases found?
Africa Asia (India, China)
114
Cause TB
Mycobacteria Acid Fast Bacilli -- M. Tuberculosis M. Bovis - unpasteurised milk M. Africanum M. microti
115
How is TB transferred?
Via inhalation - AIRBORNE OR drinking unpasteurised milk
116
How to stain for Mycobacteria?
Ziehl-Neelsen stain Stains **RED / PINK** !!
117
RF TB
Country - TRAVEL!! (e.g. travelled to India) IVDU Homeless/Crowded housing Alcoholic Prisons HIV+ Immunosuppression
118
Pathophysiology TB
1. TB bacteria is ingested by alveolar macrophages BUT bacteria resist being killed! ∴ granuloma forms 2. T cells recruited, surround granuloma. Central part of granuloma undergoes NECROSIS - forms _caseating granuloma_ called **1º GHON FOCUS** 3. Ghon focus spreads to lymph nodes! GHON FOCUS + LYMPH NODE SPREAD = **GHON COMPLEX** 4. 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
119
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
120
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
121
Describe the bacteria causing TB
MYCOBACTERIAL (TB, bovis, africanum, microti) "Acid fast" bacilli Slightly curved Beaded bacilli
122
Stain for TB bacteria
MYCOBACTERIAL SPECIES Stain with **Ziehl-Neesen** stain STAINS RED/PINK
123
Why is TB bacteria resistant to gram stain?
Bc high lipid content w/ mycolic acids in cell wall
124
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
125
Where is TB commonly found?
South Asia (India, China, Pakistan) Sub-saharan Africa
126
Tx TB & its assoc S/E
**RIPE** **R**ifampicin - *R**ed urine **I**soniazid - per**I**pheral neuropathy (∴ give VitB6 alongside) **P**yramidine - he**P**atitis **E**thambutol - **E**ye problems (optic Neuritis) RI = 2 months PE = 6 months
127
What must you remember to do after diagnosing a TB patient?
Report to Public Health England !
128
Quick! Chronic illness w/ Fever, weight loss, night sweats What is it?
Think TB! But obvs rule out malignancy
129
What is the most common interstitial lung disease?
Pulmonary fibrosis
130
Inheritance pattern Cystic Fibrosis
Autosomal recessive
131
Most Patients with CF also have?
Pancreatic insufficiency
132
RF CF
FHx Caucasian
133
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!
134
CFTR full name & where is it found?
cystic fibross transmembrane conductance regulator Long arm of Chromosome 7
135
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
136
WHY do you get pancreatic insufficiency with CF?
Bc enzymes are not released to digest fat
137
Why do you get male infertility with CF?
Atrophy of vas deferens and epididymis
138
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,
139
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
140
Comps CF
BRONCHIECTASIS Recurrent infections
141
What is Bronchiectasis?
Chronic infection of bronchi and bronchioles which causes permanent dilation of central/mid-sized airways
142
MC pathogen in Bronchiectasis And also pathogen indicating worse prognosis
Haemophilus Influenzae = MC But also bad = Pseudomonas aeruginosa
143
What bacteria is Pseudomonas Aeruginosa? (like gram stain etc)
Gram negative, Aerobic, oxidase positive (?) bacteria
144
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
145
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)
146
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
147
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)
148
Tx Bronchiectasis
No Cure! -- Chest physio Stop smoking Bronchodilators - SABA Anti-inflamm - azithromycin (↓exacerbations) Prophylactic Abx
149
Pseudomonas aeruginosa Abx
Ciprofloxacin
150
What type of HS reaction is Hypersensitivity Pneumonitis?
Type 3 !!
151
RF Hypersensitivity Pneumonitis
Occupation!!! e.g. farming KEEPING BIRDS Regular use of hot tubs
152
Pathophysiology Hypersensitivity Pneumonitis
Type 3 HS reaction after exposure to inhaled allergen ∴ causes alveolar and bronchial inflammation
153
Signs / Symptoms Hypersensitivity Pneumonitis
154
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
155
Tx Hypersensitivity Pneumonitis
Remove allergen!! Use steroids if severe
156
Ix Hypersensitivity Pneumonitis
History!!!!!!!!!!!! Usually diagnosed w history and examination CXR - patchy, nodular infiltrates Fibrosis if fibrotic HP
157
What is Sarcoidosis characterised by?
Non-caseating granulomas throughout the body!
158
What is Sarcoidosis?
Idiopathic multi-system granulomatous disease w lung involvement in 90% of cases
159
RF Sarcoidosis
African american!! Females 20-40s FHx Prior infection w Mycobacterium Tuberculosis
160
How is sarcoidosis often found?
Incidentally on routine XR
161
What is the typical patient of Sarcoidosis?
20 - 40 year old Afro-Caribbean woman
162
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
163
Signs / Symptoms Lofgren's syndrome
TRIAD OF : 1. Erythema Nodosum 2. Bilateral hilar lymphadenopathy 3. Acute polyarthritis (MC = ankles)
164
What is Lofgren's syndrome?
Subset of sarcoidosis
165
Ix Sarcoidosis
Bloods - ↑ACE and ↑ Ca+ CXR! - bilateral hilar lymphadenopathy & pulmonary infiltrates STAGING **GS!!!!!** BIOPSY - shows non-caseating granuloma
166
Why is there hypercalcaemia in Sarcoidosis?
Bc XS vit D produced by macrophages
167
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)
168
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
169
Define Pulmonary HTN
mPAP > 25 mmHg
170
What is mPAP?
Mean arterial pulmonary arterial pressure
171
Define mild, moderate and severe Pulmonary HTN
mPAP = Mild 25-40 Mod 40 - 55 Severe 55+ mmHg
172
Causes Pulmonary HTN
Pre-Capillary : 1º pul htn, pul emboli! Capillary : COPD, asthma Post-Capillary : LV failure Chronic hypoxaemia - COPD, high altitude
173
Pathophysiology Pul HTN
Hypoxaemia causes **reactive pulmonary vasoconstriction** bc body thinks this is dead space!! ∴ RVH and resp failure
174
How is mPAP measured?
w/ Right heart catheterisation
175
Signs / Symptoms Pul HTN
Exertional dyspnoea Fatigue RH failure signs ! - ↑JV, periph oedema, loud S2
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Ix Pul HTN
CXR - RVH ECG - RA dilation - peaked P waves > 2.5mm Echo - RVH **GS!!!!!* right heart catheter (>25mmHg)
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Tx Pul HTN
**Phosphodiesterase-5-inhibitor aka Sildenafil aka VIAGRA** CCB - amlodopine Endothelin-1-antagonist e.g. bosentan Diuretics - oedema
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Comps Pul HTN
COR PULMONALE
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Prevention Pneumonia
Polysaccharide pneumococcal vaccine
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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
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Causes Transudative pleural effusion
↑BP or low protein count e.g. Congestive HF, fluid overload, Hypoalbuminaemia (liver cirrhosis, nephrotic), constrictive pericarditis
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Causes Exudative Pleural effusion
Inflammation causing ↑ vascular permeability e.g. pneumonia, lung cancer, TB, SLE
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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
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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
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What is tactile fremitus? Why is it decreased w pleural effusion?
Vibration that occurs when we speak Bc effusion absorbs some of the vibrations
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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
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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
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When in a lifetime does spontaneous pneumothorax often occur?
Between 20 - 40 years old
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Types of pneumothorax
**Spontaneous** Traumatic Iatrogenic Lung pathology Tension! - emergency
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What is a pneumothoax?
Air in the pleural space Causes lungs to collapse
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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
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One big difference between Pneumothorax and Pleural effusion
Pneumothorax has : Hyperresonant percussion ipsilaterally while pleural effusion has: Stony dull percussion ipsilaterally
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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
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RF Pneumothorax
Male Tall & thin Smoking Age Mechanical ventilation
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DDx Pneumothorax
Pleural effusion PE
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Ix Pneumothorax
**CXR** - GS!!!! Absent lung markings Tracheal deviation to OTHER side Affected area - much darker DO NOT DO IF SUSPECT TENSION PNEUMOTHORAX - WASTES TIME -- ABG CT is more sens, do for small pneumothorax
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Tx CXR
If asymptomatic, self-healing If symptomatic, needle aspiration (2nd ICS) OR chest drain (more long term Tx) Recurrent - pleurodesis (surgery)
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What is tension pneumothorax?
MEDICAL EMERGENCY
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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)
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Signs / Symptoms Tension Pneumothorax
Cardiopulmonary deterioration! - Hypotension, Resp distress, ↓ Sats, Tachycardia, Shock Severe chest pain
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Tx Tension Pneumothorax
!!!! Insert large bore cannula into 2nd ICS @ midclav line Needle decompress first THEN chest drain !!!!
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Ix Tension Pneumothorax
Usually obvious Go straight to Tx !!!
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What is Otitis media?
Inflamed middle ear usually in children
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Causes Otitis Media
Bacterial - Streptococci or viral
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Ix Otitis Media
Otoscopy shows inflamed erythematous tympanic membrane
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What is sinusitis?
Inflamed mucosa of nasal cavity & nasal sinuses
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Causes Sinusitis
Mostly viral (< 10 days, non-purulent discharge) Bacterial (> 10 days, purulent discharge) - S. pneumo, H. influenzae
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What are Sinusitis and Otitis Media assoc with?
Meningitis!! Contiguous spread - directly to meninges
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Tx Bacterial Sinusitis
Amoxicillin
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Where do emboli of PE usually arise from?
From thrombi in iliofemoral veins - DVT
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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
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Signs / Symptoms PE
Sudden onset SOB Pleuritic chest pain Haemoptysis Hypotension Tachypnoea Pleural rub Pleural effusion tachycardia ↑ JVP
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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
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Tx PE
LMWH e.g. enoxaparin or dalteparin initially then warfarin once confirmed
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In whom is idiopathic pulmonary fibrosis found in?
Older men (60+) who smoke
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RFs Idiopathic pul fibrosis
Smoking Occupation e.g. dust Drugs - methotrexate Viruses - EBV, CMV
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Pathophysiology Idiopathic pul fibrosis
Progressive scarring leading to Type 1 resp failure No known cause
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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
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Signs / Symptoms Idiopathic pul fibrosis
Exertional dyspnoea Dry cough
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Tx Idiopathic Pulmonary fibrosis
Stop smoking + vaccines **Pirfenidone, nintedanib** Lung transplant - last resort!
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What is Hypersensitivity Pneumonitis aka?
Extrinsic Allergic Alveolitis
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Mouldy hay antigen
Micropolyspora faeni
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Mould on grape antigen
Botrytis
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What is SARS?
Severe Acute resp syndrome - emergency resp infection! Assoc w coronavirus Outbreak from China Resp failure
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Where is Avian flu seen?
SE Asian
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Signs / Symptoms Sinusitis
Frontal headache Facial pain Fever Purulent nasal discharge Tenderness
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What is Acute Epiglottitis?
Usually in children < 5 years but also in adults! Inflam of epiglottis Rare now bc Hib vaccine
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What is the epiglottis?
Flap of cartilage behind root of tongue
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Causes Epliglottitis
H. inflenzae type B (Hib) Causes of pharyngtitis and other bacterial infections of airway
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Signs / Symptoms Epiglottitis
Sore throat Odynophagia High pitched wheeze - insp stridor Diarrhoea Fatigue Weight loss Severe airflow obstruction Meningitis Septic arthritis Osteomyelitis
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Tx Epiglottitis
IV ABx - Amoxicillin, Co-amoxiclav etc Endotracheal intubation
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Causes Whooping Cough
Bordatella pertussis
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Describe Bordatella pertussis In terms of gram stain etc
Gram neg, aerobic coccobacillus (ROD)
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Signs / Symptoms Whooping Cough
Chronic cough Classic insp whoop Vomiting Malaise Anorexia Rhinorrhoea
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Tx Whooping Cough
Antimicrobials - clarithromycin Vaccination
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Signs / Symptoms Croup
Prominent barking cough Febrile Resp rate = 40 Cyanosis Insp stridor Hoarse throat
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Cause Silicosis
Inhalation of sillicon dioxide
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Ix Silicosis
EGGSHELL calcification of hilar lymph nodes
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What is Asbestosis?
Inhalation of asbestos Affects pleura
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Ix Asbestosis
Type 1 resp failure picture Microscopy - ferruginous bodies (yellow/brown rod shaped) CLUBBING MORE LIKELY THAN IN SILICOSIS
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Name the types of Pneumoconiosis
Asbestosis Silicosis
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What's the most common ILD?
Idiopathic pul fibrosis
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Name the drugs that induce Interstitial lung disease
Bleomycin - Hodgkin's! Amiodarone Nitrofurantoin
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Connective tissue IDL types
Scleroderma RA
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RF Pneumoconiosis
Electrician Joiner Plumber Typically worked around 1980s
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Types of Lung cancers (that i care about)
Pleural - Mesothelioma Bronchial - Small cell & then squamous, adenocarcinoma
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1º Metastasis sites Lung cancers
Bone Liver Adrenals - usually ASx Brain Lymph nodes
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Cause Mesothelioma
ASBESTOS !! - usually don't present until decades after exposure
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Pleural or Broncial Carcinoma - MC?
BRONCHIAL
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Cancer with smoking assoc?
SMALL CELL LUNG CANCER
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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
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Other than pleura, sites of mesothelial cancer please
Mesothelial cells of : Peritoneum Pericardium Testes
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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
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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!
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Tx Mesothelioma
Palliative :( If found early, might do surgery/chemo etc But usually resistant :( V aggressive tumour, avg survival ~ 1 year
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Why doesn't Mesothelioma distantly mets?
Bc affects pleura Pleura isn't found everywhere in the body
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Who does SCLC affect?
Exclusively smokers!!!
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What Paraneoplastic syndromes can SCLC cause?
Ectopic ACTH - Cushing's Ectopic ADH - SIADH Lambert Eaton syndrome
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Describe SCLC
Fast growing Early mets
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What is Small Cell Lung Cancer?
Malignancy affecting central resp system - bronchi!
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Signs / Symptoms SCLC
Cancer B Sx Compression Sx Cough Haemoptysis SOB Recurrent chest pain Mets early ∴ Mets Sx - bone pain
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List Bronchial Carcinomas in order of MC to LC
Adenocarcinoma SCC SCLC
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Ix SCLC
1st Line - CXR, _then_ CT **GS!!!!* - BRONCHOSCOPY + BIOPSY Appears as small cells w minimal cytoplasm Staging
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Tx SCLC
If caught early, try chemo/radio Usually palliative :(
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What is Adenocarcinoma?
Bronchial carcinoma arising from mucus secreting glandular epithelium!!
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RF Adenocarcinoma
ASBESTOS
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Where does Adenocarcinoma affect?
Peripheral lung but can be central
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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
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Ix Adenocarcinoma
1st Line - CXR, _then_ CT **GS!!!** BRONCHOSCOPY + BIOPSY TNM STAGING
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Tx Adenocarcinoma
Relatively treatable! :) Chemo +/- radiotherapy Surgical excision sometimes
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Paraneoplastic Syndrome of Squamous Cell Carcinoma
PTHrP ∴ Hypercalcaemia
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Describe the mets of Squamous Cell carcinoma
Mets late Spreads locally usually
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What is Squamous Cell Carcinoma?
Bronchial carcinoma arising from lung epithelium that resembles SQUAMOUS epithelium!
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Assoc of NSCLC (Both SCC and Adenocarcinoma)
HYPERTROPHIC PULMONARY OSTEOARTHROPATHY Triad : 1. Clubbing 2. Arthritis 3. Long bone swelling
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Who does Squamous cell carcinoma affect?
Smokers! More than any other NON-SCLC
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Signs / Symptoms SCC
Cancer B Sx Compression Sx Cough Haemoptysis SOB Recurrent chest pain
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Ix SCC
1st Line - CXR, _then_ CT **GS!!!** BRONCHOSCOPY + BIOPSY TNM STAGING
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Tx SCC
Usually surgical excision ! If mets - chemo/radio
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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)
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