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Phase 2 Quick > Resp > Flashcards

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
Q

How is A1AT def inherited?

A

Autosomal codominant

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26
Q

Pathophysiology A1AT def

A

A1AT degrades neutrophil elastase
∴ deficiency = panacinar emphysema and liver issues

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27
Q

A1AT associations

A

LIVER ISSUES
don’t forget!
Might present with liver stuff (mild RUQ pain, ↑bilirubin, ↑ALP etc)

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28
Q

Comp Emphysema

A

Bullae

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29
Q

COPD Big sign in XR

A

Flattened diaphragm
Hyperinflation of lungs

BARREL CHEST!!

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30
Q

Ix COPD

A

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

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31
Q

What is COPD characterised by?

A

Neutrophilic inflammation

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32
Q

Describe micro? or macro?scopic features of COPD

A

Lots of inflam, fibrosis and alveolar disruption
LITTLE smooth muscle hypertrophy and basement membrane thickening

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33
Q

Describe the values for the stages of COPD

A

FEV1 % - compared to predicted value
STAGE 1 - ≥ 80% (mild)
STAGE 2 - 50 - 79% (moderate)
STAGE 3 - 30 - 49% (severe)
STAGE 4 - < 30% (v severe)

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34
Q

Tx COPD
Long term management

A

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)

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35
Q

Comps COPD

A

Cor pulmonale
RHF - bc ↑↑↑Portal HTN
↑ Infection risk

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36
Q

Main pathogens in acute COPD exacerbations

A

S. Pneumoniae
H. influenzae

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37
Q

Tx COPD
Exacerbations

A

O2 - TARGET 88-92%
Nebulised Salbutamol + ipratropium bromide
ICS
Abx

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38
Q

What is the O2 sat target for COPD patients?
WHY?

A

Patients are chronic CO2 retainers

XS O2 = ↑Dead space
∴ ↑ V/Q mismatch
∴ ↑ CO2 retention
RESP ACIDOSIS

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39
Q

Comps COPD exacerbations

A

↓ QoL
↑ Economic costs
↑ Mortality
↓ Lung function
Sx decline

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40
Q

Indications for hospital admission
(COPD)

A

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

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41
Q

Ix COPD exacerbations

A

ABG
Chest radiograph
ECG
WBC

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42
Q

What are some indications a COPD patient should be put on LTOT?

A

Chronic readings of <88% O2 sat
OR
O2 < 90% + HF

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43
Q

What is an important condition when on LTOT?
Why?

A

MUST STOP SMOKING
Bc you’ll blow up and die

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44
Q

SABA and LABA
What are they?
MOA?

A

Beta agonists - short acting beta2 agonists and long acting beta2 agonists

↑cAMP ∴ smooth muscle relaxation

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45
Q

SAMA and LAMA
What are they?
MOA?

A

Muscarinic antagonists - Short acting/Long acting muscarinic antagonists

↑cGMP degradation
∴ smooth muscle relaxation

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46
Q

ICS stands for?

A

Inhaled corticosteroids

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47
Q

Surgery option for very very severe COPD

A

Lung vol reduction surgery (LVRS)

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48
Q

Note for treating COPD w ICS

A

Avoid chronic treatment
bc benefit-to-risk ratio isn’t worth it

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49
Q

What is Asthma?

A

Chronic REVERSIBLE airway disease

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50
Q

Types of Asthma

A

Allergic (70%) - IgE (T1HS), EXTRINSIC
Environmental triggers, genetics(?), hygiene hypothesis!
↑ EOSINOPHILS

Non-Allergic (30%) - non-IgE, INTRINSIC
May present later, assoc w/ smoking! §

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51
Q

Triggers for Asthma

A

Infection
Allergens
Cold weather
Exercise
Drugs - BB, aspirin

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52
Q

What is the atopic triad?

A

Atopic rhinitis
Asthma
Eczema

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53
Q

What is Asthma characterised by?

A

REVERSIBLE airway obstruction
Airway hyper-responsiveness
Inflamed bronchioles
Mucus hypersecretion

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54
Q

Pathophysiology Asthma

A

Over-expression of TH2 cells (lymphocytes) in airways (bc of trigger)
∴ IgE production (mast cell degran) + Eosinophilia

∴ Chronic remodelling and Mucus Hypersecretion !!

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55
Q

Signs / Symptoms Asthma

A

Dry cough w DIURNAL VARIATION (worse in mornings) and worse during episodes!
Dyspnoea
Tight chest
Bilateral wheeze on ausc!
Usually younger patient!

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56
Q

Describe the wheeze in Asthma

A

Bilateral
Episodic
Polyphonic
Expiratory
Widespread

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57
Q

What does microscopy of asthma show?

A

Curshmann spirals
Charcot-Leydig crystals

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58
Q

Describe Mild/Moderate Asthma episode

A

PEFR > 50%
Resp rate < 25
Pulse < 110
Normal speech

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59
Q

Describe a Severe Asthma episode

A

PEFR 33-50% predicted
RR ≥ 25
HR ≥ 110
Inability to complete sentences

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60
Q

Describe a Life-threatening asthma episode

A

PEFR < 33%
SaO2 < 92% or PaO2 < 8kPa
Normal PaCO2
Altered conscious level! Exhaustion, arrhythmia, hypotension, silent chest! cyanosis, poor effort

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61
Q

Ix Asthma Attack

A

PEFR
Oximetry
ABG

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62
Q

Describe a near-fatal asthma attack

Like patient nearly DIED
the worst it could be

A

↑PaCO2

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63
Q

Ix Asthma

A
  1. FeNO
  2. Spirometry (Obstructive picture)
  3. Bronchodilator Reversibility test > 12% - shows reversible!!
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64
Q

Tx Asthma Exacerbations

A

O SHIT ME
O2

Nebulised SABA
Hydrocortisone (ICS)
Ipratropium Bromide
Theophylline - IV

MgSO4 IV
Escalate care

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65
Q

Tx Asthma

A
  1. SABA (PRN)
  2. ## SABA + ICSBefore progressing, ensure technique and compliance is calm
    –
  3. SABA + ICS + LTRA
  4. SABA + ICS + LABA +/- LTRA
  5. ↑ ICS dose
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66
Q

What does LTRA stand for?
Give an example

A

Leukotriene Receptor Antagonist
e.g. Montelukast

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67
Q

Examples of SABA

A

Salbutamol
Terbutaline

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68
Q

Examples of LABA

A

Salmeterol
Formoterol

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69
Q

What happens with B2-agonists at high doses?

A

Not selective
Will act on other receptors (e.g. B1 in heart, B3 in adipose tissue)

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70
Q

SAMA examples

A

Ipratropium bromide

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71
Q

LAMA examples

A

Tiotropium bromide

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72
Q

ICS examples

A

Prednisolone
Beclomethasone

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73
Q

Why should you not give BB to asthmatics?

A

It causes bronchoconstriction

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74
Q

When do you give SAMA?
(general answer)

A

In acute exacerbations

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75
Q

Ix Asthma

A

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

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76
Q

Quick!
Miosis, Ptosis, Anhidrosis - What is it?

A

Horner’s syndrome

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77
Q

What is a pancoast tumour?
What can it cause? How does this present?

A

Resp tumour that compresses T1-L2
Can cause ipsilateral horner’s syndrome
Presents with : Miosis, Ptosis, Anhidrosis!!

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78
Q

What is Pemberton’s sign?
What does it mean?

A

Raising arms causes facial flushing
Means Superior vena cava obstruction bc compression

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79
Q

RIPE
Length and S/E

A

Rifampicin - 6 months, Red/bloody urine

Isoniazid - 6 months, perIpheral neuropathy

Pyrazinamide - 2 months, hePatitis & gout & arthralgia

Ethambutol - 2 months, Eye problems (optic neuritis)

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80
Q

HAP Def

A

Pneumonia acquired at least 48 hours after admission

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81
Q

Atypical pneumonia definition

A

Cause by atypical organisms, not detectable by gram stain

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82
Q

CAP Organisms

A

SMH

Streptococcus pneumoniae
Moraxella Caterhalis
Haem. Influenzae

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83
Q

HAP Organisms

A

Peakkkkkksss

Psuedomonas aeruginosa
E.Coli
Klebsiella
Staphylococcus

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84
Q

Organisms causing pneumonia in immunocomp patients

A

Pneumocystis jiroveci

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85
Q

Atypical pneumonia organisms

A

Legionella pneumophilia
Mycoplasma pneumoniae
Chlamydia
Clamydophila pneumoniae
Coxiella burnetti

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86
Q

Water cooler/Air conditioner orgnisms?

A

Legionella

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87
Q

If HIV patient, which organism caused their pneumoniae?

A

Pneumocystis jiroveci !!
(fungal)

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88
Q

Define pneumonia

A

Inflammation of lung parenchyma
Usually due to infection that affects distal airways
Forms inflam exudate

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89
Q

What patients are most inclined to get HAP?

A

Elderly
Ventilator assisted
Post-op

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90
Q

Extrapulmonary features of Mycoplasma pnemoniae

A

Erythema Multiforme

Haemolytic anaemia
Encephalitis
Raynaud’s
Bullous myringitis - blisters on tympanic membrane

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91
Q

Extrapulmonary features of Legionella pneomophilia

A

Diarrhoea
Abnormal LFTs
Hyponatraemia
Myalgia, ↑CK
Interstitial nephritis
Encephalitis

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92
Q

What is Klebsiella pneumoniae assoc with?

A

Homeless
Alcoholic
Hospital

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93
Q

What is Chlamydophilai psittaci assoc w?

A

Sick birds - parrots
Poultry workers

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94
Q

What is Coxiella Brunetti assoc w?

A

Partuent animals - sheep

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95
Q

If in ITU, what organism are patients most likely to be infected with?

A

Psuedomonas aeruginosa
Haemophilus influenzae
Staph. Aureus (MRSA)

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96
Q

Why is HAP more severe than CAP?

A

Bc most of the causative organisms are drug resistant
e.g. MRSA

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97
Q

Viral causes Pneumoniae

A

CMV
H.flu

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98
Q

Name an AIDS defining illness

A

Pneumocystis Pneumonia

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99
Q

RF Pneumonia

A

Immuno comp
IVDU
Pre-existing Resp disease
Very young/Old

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100
Q

Pathophysiology Typical Pneumonia

A

Bacteria invades
Exudate forms INSIDE alveoli lumen Sputum!

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101
Q

Pathophysiology Atypical Pneumonia

A

Bacteria invades
Exudate forms in interstitium of alveoli
Dry cough

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102
Q

Signs / Symptoms Pneumonia

A

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

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103
Q

Ix Pneumonia

A

CXR - GS!!
Shows consolidation
AIR BRONCHOGRAM - fluid filled alveoli?

FBC
Sputum microscopy, culture, sens + gram stain

Test for TB if clinical features suggest!!

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104
Q

Which causative organism does rusty sputum in pneumonia suggest?

A

S. pneumoniae

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105
Q

What does the CURB score measure?

A

Pneumonia risk and how to manage patient

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106
Q

Describe the CURB score

A

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!

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107
Q

Tx Pneumonia

A

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

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108
Q

Comps Pneumonia

A

Parapneumonic effusion
Epyema

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109
Q

When is Aspiration pneumonia seen?

A

In patients with stroke, bulbar palsy and Myasthenia Gravis

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110
Q

What is aspiration pneumonia?

A

Aspiration of gastric contents into lungs
Can be fatal bc gastric acid damages lungs

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111
Q

What is Tuberculosis?

A

Granulomatous caseating disease cause by Mycobacteria

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112
Q

Cause Cystic Fibrosis

A

Mutation in CFTR gene

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113
Q

Where are the majority of TB cases found?

A

Africa
Asia (India, China)

114
Q

Cause TB

A

Mycobacteria
Acid Fast Bacilli
–
M. Tuberculosis
M. Bovis - unpasteurised milk
M. Africanum
M. microti

115
Q

How is TB transferred?

A

Via inhalation - AIRBORNE
OR drinking unpasteurised milk

116
Q

How to stain for Mycobacteria?

A

Ziehl-Neelsen stain
Stains RED / PINK !!

117
Q

RF TB

A

Country - TRAVEL!! (e.g. travelled to India)
IVDU
Homeless/Crowded housing
Alcoholic
Prisons
HIV+
Immunosuppression

118
Q

Pathophysiology TB

A
  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
Q

Extrapulmonary manifestations TB

A

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
Q

Signs / Symptoms TB

A

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
Q

Describe the bacteria causing TB

A

MYCOBACTERIAL (TB, bovis, africanum, microti)

“Acid fast” bacilli
Slightly curved
Beaded bacilli

122
Q

Stain for TB bacteria

A

MYCOBACTERIAL SPECIES

Stain with Ziehl-Neesen stain
STAINS RED/PINK

123
Q

Why is TB bacteria resistant to gram stain?

A

Bc high lipid content w/ mycolic acids in cell wall

124
Q

Ix TB

A

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
Q

Where is TB commonly found?

A

South Asia (India, China, Pakistan)
Sub-saharan Africa

126
Q

Tx TB & its assoc S/E

A

RIPE

Rifampicin - *Red urine
Isoniazid - perIpheral neuropathy (∴ give VitB6 alongside)
Pyramidine - heP**atitis
Ethambutol - Eye problems (optic Neuritis)

RI = 2 months
PE = 6 months

127
Q

What must you remember to do after diagnosing a TB patient?

A

Report to Public Health England !

128
Q

Quick!
Chronic illness w/ Fever, weight loss, night sweats
What is it?

A

Think TB!
But obvs rule out malignancy

129
Q

What is the most common interstitial lung disease?

A

Pulmonary fibrosis

130
Q

Inheritance pattern Cystic Fibrosis

A

Autosomal recessive

131
Q

Most Patients with CF also have?

A

Pancreatic insufficiency

132
Q

RF CF

A

FHx
Caucasian

133
Q

Pathophysiology CF

A

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
Q

CFTR full name & where is it found?

A

cystic fibross transmembrane conductance regulator
Long arm of Chromosome 7

135
Q

Signs / Symptoms CF

A

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
Q

WHY do you get pancreatic insufficiency with CF?

A

Bc enzymes are not released to digest fat

137
Q

Why do you get male infertility with CF?

A

Atrophy of vas deferens and epididymis

138
Q

Ix CF

A

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
Q

Tx CF

A

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
Q

Comps CF

A

BRONCHIECTASIS
Recurrent infections

141
Q

What is Bronchiectasis?

A

Chronic infection of bronchi and bronchioles which causes permanent dilation of central/mid-sized airways

142
Q

MC pathogen in Bronchiectasis
And also pathogen indicating worse prognosis

A

Haemophilus Influenzae = MC
But also bad = Pseudomonas aeruginosa

143
Q

What bacteria is Pseudomonas Aeruginosa?
(like gram stain etc)

A

Gram negative, Aerobic, oxidase positive (?) bacteria

144
Q

Signs / Symptoms Bronchiectasis

A

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
Q

Pathophysiology Bronchiectasis

A

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
Q

Causes Bronchiectasis

A

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
Q

Ix Bronchiectasis

A

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
Q

Tx Bronchiectasis

A

Chest physio
Stop smoking
Bronchodilators - SABA
Anti-inflamm - azithromycin (↓exacerbations)

Prophylactic Abx

149
Q

Pseudomonas aeruginosa Abx

A

Ciprofloxacin

150
Q

What type of HS reaction is Hypersensitivity Pneumonitis?

A

Type 3 !!

151
Q

RF Hypersensitivity Pneumonitis

A

Occupation!!! e.g. farming
KEEPING BIRDS
Regular use of hot tubs

152
Q

Pathophysiology Hypersensitivity Pneumonitis

A

Type 3 HS reaction after exposure to inhaled allergen
∴ causes alveolar and bronchial inflammation

153
Q

Signs / Symptoms Hypersensitivity Pneumonitis

A
154
Q

Types Hypersensitivity Pneumonitis

A

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
Q

Tx Hypersensitivity Pneumonitis

A

Remove allergen!!
Use steroids if severe

156
Q

Ix Hypersensitivity Pneumonitis

A

History!!!!!!!!!!!!
Usually diagnosed w history and examination

CXR - patchy, nodular infiltrates
Fibrosis if fibrotic HP

157
Q

What is Sarcoidosis characterised by?

A

Non-caseating granulomas throughout the body!

158
Q

What is Sarcoidosis?

A

Idiopathic multi-system granulomatous disease w lung involvement in 90% of cases

159
Q

RF Sarcoidosis

A

African american!!
Females
20-40s
FHx
Prior infection w Mycobacterium Tuberculosis

160
Q

How is sarcoidosis often found?

A

Incidentally on routine XR

161
Q

What is the typical patient of Sarcoidosis?

A

20 - 40 year old Afro-Caribbean woman

162
Q

Signs / Symptoms Sarcoidosis

A

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
Q

Signs / Symptoms Lofgren’s syndrome

A

TRIAD OF :
1. Erythema Nodosum
2. Bilateral hilar lymphadenopathy
3. Acute polyarthritis (MC = ankles)

164
Q

What is Lofgren’s syndrome?

A

Subset of sarcoidosis

165
Q

Ix Sarcoidosis

A

Bloods - ↑ACE and ↑ Ca+

CXR! - bilateral hilar lymphadenopathy & pulmonary infiltrates
STAGING

GS!!!!! BIOPSY - shows non-caseating granuloma

166
Q

Why is there hypercalcaemia in Sarcoidosis?

A

Bc XS vit D produced by macrophages

167
Q

Describe the staging for Sarcoidosis

A

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
Q

Tx Sarcoidosis

A

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
Q

Define Pulmonary HTN

A

mPAP > 25 mmHg

170
Q

What is mPAP?

A

Mean arterial pulmonary arterial pressure

171
Q

Define mild, moderate and severe Pulmonary HTN

A

mPAP =

Mild 25-40
Mod 40 - 55
Severe 55+

mmHg

172
Q

Causes Pulmonary HTN

A

Pre-Capillary : 1º pul htn, pul emboli!

Capillary : COPD, asthma

Post-Capillary : LV failure

Chronic hypoxaemia - COPD, high altitude

173
Q

Pathophysiology Pul HTN

A

Hypoxaemia causes reactive pulmonary vasoconstriction
bc body thinks this is dead space!!

∴ RVH and resp failure

174
Q

How is mPAP measured?

A

w/ Right heart catheterisation

175
Q

Signs / Symptoms Pul HTN

A

Exertional dyspnoea
Fatigue
RH failure signs ! - ↑JV, periph oedema, loud S2

176
Q

Ix Pul HTN

A

CXR - RVH

ECG - RA dilation - peaked P waves > 2.5mm

Echo - RVH

**GS!!!!!* right heart catheter (>25mmHg)

177
Q

Tx Pul HTN

A

Phosphodiesterase-5-inhibitor aka Sildenafil aka VIAGRA
CCB - amlodopine
Endothelin-1-antagonist e.g. bosentan

Diuretics - oedema

178
Q

Comps Pul HTN

A

COR PULMONALE

179
Q

Prevention Pneumonia

A

Polysaccharide pneumococcal vaccine

180
Q

Types of Pleural Effusion

A

TRANSUDATIVE - due to ↑hydrostatic pressure or oncotic pressure
LOW PROTEIN COUNT < 25g/L
TRANSPARENT

EXUDATIVE - due to inflammation
HIGH PROTEIN COUNT > 35g/L
CLOUDY

181
Q

Causes Transudative pleural effusion

A

↑BP or low protein count
e.g. Congestive HF, fluid overload, Hypoalbuminaemia (liver cirrhosis, nephrotic), constrictive pericarditis

182
Q

Causes Exudative Pleural effusion

A

Inflammation causing ↑ vascular permeability
e.g. pneumonia, lung cancer, TB, SLE

183
Q

Signs / Symptoms Pleural effusion

A

Stony dull percussion on ipsilateral side
↓ Breath sounds
Dyspnoea
Trachea deviation AWAY from effusion - if large effusion
Cough
Pleuritic chest pain
↓ Tactile fremitus

184
Q

Ix Pleural effusion

A

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

185
Q

What is tactile fremitus?
Why is it decreased w pleural effusion?

A

Vibration that occurs when we speak
Bc effusion absorbs some of the vibrations

186
Q

Tx Pleural effusion

A

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

187
Q

Patients with a spontaneous pneumothorax often tend to be?

A

Tall and thin young males
Might have connective tissue disorder - Marfan’s/ED +/- a smoker / trauma

188
Q

When in a lifetime does spontaneous pneumothorax often occur?

A

Between 20 - 40 years old

189
Q

Types of pneumothorax

A

Spontaneous
Traumatic
Iatrogenic
Lung pathology
Tension! - emergency

190
Q

What is a pneumothoax?

A

Air in the pleural space
Causes lungs to collapse

191
Q

Signs / Symptoms Pneumothorax

A

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

192
Q

One big difference between Pneumothorax and Pleural effusion

A

Pneumothorax has :
Hyperresonant percussion ipsilaterally

while pleural effusion has:
Stony dull percussion ipsilaterally

193
Q

Causes Pneumothorax

A

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

194
Q

RF Pneumothorax

A

Male
Tall & thin
Smoking
Age
Mechanical ventilation

195
Q

DDx Pneumothorax

A

Pleural effusion
PE

196
Q

Ix Pneumothorax

A

CXR - GS!!!!
Absent lung markings
Tracheal deviation to OTHER side
Affected area - much darker

ABG
CT is more sens, do for small pneumothorax

197
Q

Tx CXR

A

If asymptomatic, self-healing
If symptomatic, needle aspiration (2nd ICS)
OR chest drain (more long term Tx)

Recurrent - pleurodesis (surgery)

198
Q

What is tension pneumothorax?

A

MEDICAL EMERGENCY

199
Q

Pathophysiology Tension Pneumothorax

A

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)

200
Q

Signs / Symptoms Tension Pneumothorax

A

Cardiopulmonary deterioration! - Hypotension, Resp distress, ↓ Sats, Tachycardia, Shock

Severe chest pain

201
Q

Tx Tension Pneumothorax

A

!!!!
Insert large bore cannula into 2nd ICS @ midclav line
Needle decompress first
THEN chest drain
!!!!

202
Q

Ix Tension Pneumothorax

A

Usually obvious
Go straight to Tx !!!

203
Q

What is Otitis media?

A

Inflamed middle ear
usually in children

204
Q

Causes Otitis Media

A

Bacterial - Streptococci
or viral

205
Q

Ix Otitis Media

A

Otoscopy shows inflamed erythematous tympanic membrane

206
Q

What is sinusitis?

A

Inflamed mucosa of nasal cavity & nasal sinuses

207
Q

Causes Sinusitis

A

Mostly viral (< 10 days, non-purulent discharge)

Bacterial (> 10 days, purulent discharge) - S. pneumo, H. influenzae

208
Q

What are Sinusitis and Otitis Media assoc with?

A

Meningitis!!
Contiguous spread - directly to meninges

209
Q

Tx Bacterial Sinusitis

A

Amoxicillin

210
Q

Where do emboli of PE usually arise from?

A

From thrombi in iliofemoral veins - DVT

211
Q

RF PE

A

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

212
Q

Signs / Symptoms PE

A

Sudden onset SOB
Pleuritic chest pain
Haemoptysis
Hypotension
Tachypnoea
Pleural rub
Pleural effusion
tachycardia
↑ JVP

213
Q

Ix PE

A

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

214
Q

Tx PE

A

LMWH e.g. enoxaparin or dalteparin initially
then warfarin once confirmed

215
Q

In whom is idiopathic pulmonary fibrosis found in?

A

Older men (60+) who smoke

216
Q

RFs Idiopathic pul fibrosis

A

Smoking
Occupation e.g. dust
Drugs - methotrexate
Viruses - EBV, CMV

217
Q

Pathophysiology Idiopathic pul fibrosis

A

Progressive scarring leading to Type 1 resp failure
No known cause

218
Q

Ix Idiopathic Pul Fibrosis

A

Spirometry = FEV1/FVC > 0.7 but FVC is low < 0.8
aka Restrictive picture

**GS!!!* HIGH RES CT = GROUND GLASS APPEARANCE OF LUNGS

219
Q

Signs / Symptoms Idiopathic pul fibrosis

A

Exertional dyspnoea
Dry cough

220
Q

Tx Idiopathic Pulmonary fibrosis

A

Stop smoking + vaccines

Pirfenidone, nintedanib

Lung transplant - last resort!

221
Q

What is Hypersensitivity Pneumonitis aka?

A

Extrinsic Allergic Alveolitis

222
Q

Mouldy hay antigen

A

Micropolyspora faeni

223
Q

Mould on grape antigen

A

Botrytis

224
Q

What is SARS?

A

Severe Acute resp syndrome - emergency resp infection!
Assoc w coronavirus
Outbreak from China
Resp failure

225
Q

Where is Avian flu seen?

A

SE Asian

226
Q

Signs / Symptoms Sinusitis

A

Frontal headache
Facial pain
Fever
Purulent nasal discharge
Tenderness

227
Q

What is Acute Epiglottitis?

A

Usually in children < 5 years but also in adults!
Inflam of epiglottis
Rare now bc Hib vaccine

228
Q

What is the epiglottis?

A

Flap of cartilage behind root of tongue

229
Q

Causes Epliglottitis

A

H. inflenzae type B (Hib)
Causes of pharyngtitis and other bacterial infections of airway

230
Q

Signs / Symptoms Epiglottitis

A

Sore throat
Odynophagia
High pitched wheeze - insp stridor
Diarrhoea
Fatigue
Weight loss
Severe airflow obstruction

Meningitis
Septic arthritis
Osteomyelitis

231
Q

Tx Epiglottitis

A

IV ABx - Amoxicillin, Co-amoxiclav etc

Endotracheal intubation

232
Q

Causes Whooping Cough

A

Bordatella pertussis

233
Q

Describe Bordatella pertussis
In terms of gram stain etc

A

Gram neg, aerobic coccobacillus (ROD)

234
Q

Signs / Symptoms Whooping Cough

A

Chronic cough
Classic insp whoop
Vomiting
Malaise
Anorexia
Rhinorrhoea

235
Q

Tx Whooping Cough

A

Antimicrobials - clarithromycin
Vaccination

236
Q

Signs / Symptoms Croup

A

Prominent barking cough
Febrile
Resp rate = 40
Cyanosis
Insp stridor
Hoarse throat

237
Q

Cause Silicosis

A

Inhalation of sillicon dioxide

238
Q

Ix Silicosis

A

EGGSHELL calcification of hilar lymph nodes

239
Q

What is Asbestosis?

A

Inhalation of asbestos
Affects pleura

240
Q

Ix Asbestosis

A

Type 1 resp failure picture
Microscopy - ferruginous bodies (yellow/brown rod shaped)

CLUBBING MORE LIKELY THAN IN SILICOSIS

241
Q

Name the types of Pneumoconiosis

A

Asbestosis
Silicosis

242
Q

What’s the most common ILD?

A

Idiopathic pul fibrosis

243
Q

Name the drugs that induce Interstitial lung disease

A

Bleomycin - Hodgkin’s!
Amiodarone
Nitrofurantoin

244
Q

Connective tissue IDL types

A

Scleroderma
RA

245
Q

RF Pneumoconiosis

A

Electrician
Joiner
Plumber
Typically worked around 1980s

246
Q

Types of Lung cancers
(that i care about)

A

Pleural - Mesothelioma
Bronchial - Small cell & then squamous, adenocarcinoma

247
Q

1º Metastasis sites Lung cancers

A

Bone
Liver
Adrenals - usually ASx
Brain
Lymph nodes

248
Q

Cause Mesothelioma

A

ASBESTOS !! - usually don’t present until decades after exposure

249
Q

Pleural or Broncial Carcinoma - MC?

A

BRONCHIAL

250
Q

Cancer with smoking assoc?

A

SMALL CELL LUNG CANCER

251
Q

TNM Classification Lung Cancer

A

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

252
Q

Other than pleura, sites of mesothelial cancer please

A

Mesothelial cells of :
Peritoneum
Pericardium
Testes

253
Q

Signs / Symptoms Mesothelioma

A

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

254
Q

Ix Mesothelioma

A

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!

255
Q

Tx Mesothelioma

A

Palliative :(
If found early, might do surgery/chemo etc
But usually resistant :(

V aggressive tumour, avg survival ~ 1 year

256
Q

Why doesn’t Mesothelioma distantly mets?

A

Bc affects pleura
Pleura isn’t found everywhere in the body

257
Q

Who does SCLC affect?

A

Exclusively smokers!!!

258
Q

What Paraneoplastic syndromes can SCLC cause?

A

Ectopic ACTH - Cushing’s
Ectopic ADH - SIADH
Lambert Eaton syndrome

259
Q

Describe SCLC

A

Fast growing
Early mets

260
Q

What is Small Cell Lung Cancer?

A

Malignancy affecting central resp system - bronchi!

261
Q

Signs / Symptoms SCLC

A

Cancer B Sx
Compression Sx
Cough
Haemoptysis
SOB
Recurrent chest pain

Mets early ∴ Mets Sx - bone pain

262
Q

List Bronchial Carcinomas in order of MC to LC

A

Adenocarcinoma
SCC
SCLC

263
Q

Ix SCLC

A

1st Line - CXR, then CT

**GS!!!!* - BRONCHOSCOPY + BIOPSY
Appears as small cells w minimal cytoplasm

Staging

264
Q

Tx SCLC

A

If caught early, try chemo/radio
Usually palliative :(

265
Q

What is Adenocarcinoma?

A

Bronchial carcinoma arising from mucus secreting glandular epithelium!!

266
Q

RF Adenocarcinoma

A

ASBESTOS

267
Q

Where does Adenocarcinoma affect?

A

Peripheral lung but can be central

268
Q

Signs / Symptoms Adenocarcinoma

A

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

269
Q

Ix Adenocarcinoma

A

1st Line - CXR, then CT

GS!!! BRONCHOSCOPY + BIOPSY

TNM STAGING

270
Q

Tx Adenocarcinoma

A

Relatively treatable! :)
Chemo +/- radiotherapy
Surgical excision sometimes

271
Q

Paraneoplastic Syndrome of Squamous Cell Carcinoma

A

PTHrP
∴ Hypercalcaemia

272
Q

Describe the mets of Squamous Cell carcinoma

A

Mets late
Spreads locally usually

273
Q

What is Squamous Cell Carcinoma?

A

Bronchial carcinoma arising from lung epithelium that resembles SQUAMOUS epithelium!

274
Q

Assoc of NSCLC
(Both SCC and Adenocarcinoma)

A

HYPERTROPHIC PULMONARY OSTEOARTHROPATHY

Triad :
1. Clubbing
2. Arthritis
3. Long bone swelling

275
Q

Who does Squamous cell carcinoma affect?

A

Smokers!
More than any other NON-SCLC

276
Q

Signs / Symptoms SCC

A

Cancer B Sx
Compression Sx
Cough
Haemoptysis
SOB
Recurrent chest pain

277
Q

Ix SCC

A

1st Line - CXR, then CT

GS!!! BRONCHOSCOPY + BIOPSY

TNM STAGING

278
Q

Tx SCC

A

Usually surgical excision !

If mets - chemo/radio

279
Q

Characteristics of Pneumocystitis Jiroveci pneumonia

A

Less productive cough than in typical pneumonia
Exercise induced desaturation
Relative lack of other clinical signs (e.g. chest clear on auscultation)

280
Q
A

Phase 2 Quick (18 decks)

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