Resp 3 Flashcards
What can cause the following types of pleural effusion?
- Transudate (<30g/l protein)
- Exudate (>30g/l protein)
- heart failure
- hypoalbuminaemia: liver failure, malabsorption, nephrotic syndrome
- hypothyroidism
- Meig’s syndrome (benign ovarian tumour which causes pleural effusion + ascites)
- infection: pneumonia, TB, subphrenic abscess
- neoplasm: lung cancer, mesothelioma, metastasis
- PE
- connective tissue disease
- pancreatitis
- dressler’s syndrome
- yellow nail syndrome
What clinical features are seen with pleural effusion?
symptoms: chest pain, breathlessness, dry cough
exam: dull percussion, reduced breath sounds, reduced chest expansion
Pleural effusion investigation
- What imaging should be carried out?
- What should be requested to be analysed in the effusion sample?
- Light’s criteria is used to differentiate a protein level of 25-35g/l between transudate and exudate. State what this entails.
- What diagnoses should you expect in effusion with:
a) low glucose
b) raised amylase
c) heavy blood staining
- CXR
- CT to determine cause
- US to guide aspiration
- pH
- protein
- cytology
- microbiology
- Lactate dehydrogenase (LDH)
- Suspect exudate if:
- pleural fluid protein / serum protein >0.5
- pleural fluid LDH / serum LDH >0.6
- pleural fluid LDH more than 2 thirds of upper limit of normal serum LDH
a)
- RA
- TB
b)
- pancreatitis
- perforated oesophagus
c)
- PE
- mesothelioma
- TB
Management of Pleural Effusion
- When should it be allowed to drain?
- How can recurrent pleural effusion be managed?
- if fluid purulent / turbid / cloudy
- if infection suspected and pH <7.2
- recurrent aspiration
- indwelling pleural catheter
- pleurodesis
- drug management to alleviate symptoms: e.g. opioids for breathlessness
Pneumothorax
- What are the RFs?
- What symptoms will suddenly come on?
- pre-existing lung disease
- Connective tissue disease: marfan’s, RA
- ventilation (incl. non-invasive)
- catamenial (entriometriosis in thorax)
- dyspnoea
- chest pain (often pleuritic)
- sweating
- tachypnoea + tachycardia
Pneumothorax management
- Describe the management guidance for
a) primary pneumothorax
b) secondary
c) iatrogenic
primary = no underlying lung disease secondary = underlying lung disease
- What advice should be given to patients on discharge regarding:
a) smoking
b) flying
c) scuba diving
- a)
- rim <2 and patient not short of breath consider discharge
- otherwise aspirate
- > if this fails insert chest drain
b)
- admit patient for 24hrs
- if patient >50 and rim >2cm or SoB insert chest drain
- otherwise if >1cm rim attempt aspiration
- > if this fails insert chest drain
- if <1cm simply give oxygen
c) majority resolve with simple observation
- a) avoid smoking to reduce further episodes
b) wait 6 weeks or 1 week after clear XR
c) permanently avoid
(would need bilateral pleurectomy and healthy lung function and CT scan post op)
Respiratory Tract Infections
There is a no antibiotic / delayed antibiotic approach to otitis media, sore throat/tonsillitis/pharyngitis, common cold, acute rhinosinusitis and acute cough/bronchitis.
Under what circumstances should antibiotics be given?
- child <2 with bilateral otitis media
- child with otorrhoea and otitis media
- sore throat / tonsillitis / pharyngitis and score 3 or more on Centor criteria
- presence of tonsillar exudate
- absence of cough
- history of fever
- tender anterior cervical lymphadenopathy or lymphadenitis
patient deemed at risk of developing complications:
- systemically unwell
- signs of serious illness (e.g. pneumonia)
- comorbidities
- acute cough and over 65 with 2 or over 80 with 1 of the following:
- congestive HF
- diabetes
- currently taking glucocorticoids
- hospitalisation in last 12 months
How long may the following infections last?
- acute otitis media
- sore throat / tonsillitis / pharyngitis
- common cold
- acute rhino sinusitis
- acute cough / bronchitis
- 4 days
- 7 days
- 1 1/2 weeks
- 2 1/2 weeks
- 3 weeks
Sarcoidosis
- Who is it commonly seen in?
- What clinical features can be seen?
- people pf African descent
- young adults
- acute: AKA Lofgren’s syndrome
- swinging fever
- bilateral hilar lymphadenopathy
- polyarthralgia
- erythema nodosum
insidious:
- cough (non-productive)
- dyspnoea
- malaise
- weight loss
skin: lupus pernio (hardened, purplish lesion on the face) - no nasolabial fold sparing (sparing seen in SLE)
hypercalcaemia
(because macrophages inside granulomas cause increased activation of vitamin D to its active form)
What syndromes can be associated with sarcoidosis?
Mikulicz syndrome
- enlargement of parotid + lacrimal glands
Heerfordt’s syndrome
- parotid enlargement
- uveitis
- fever
Sarcoidosis investigation and management
- State the stages of changes to CXR.
- What other investigations may be carried out?
- a) What treatment can be given?
b) what are the indications for this?
- stage 0 = normal
stage 1 = bilateral hilarity lymphadenopathy
stage 2 = BHL + interstitial infiltrates
stage 3 = diffuse interstitial infiltrates only
stage 4 = diffuse fibrosis - spirometry: restrictive picture
tissue biopsy: non-caseating granulomas
ACE levels: only 60% sensitive, 70% specific but can be used to monitor disease activity - a) steroids
b)
- CXR stage 2 or 3 and symptomatic
- hypercalcaemia
- neuro, eye or heart involvement
Silicosis
- What occupations are at risk?
- What clinical features are seen?
- What disease does it put a patient more at risk of?
- mining
- potteries
- foundries
- slate works
- fibrosis lung disease
- egg-shell calcification of hilarious lymph nodes
- TB
- > as silica toxic to macrophages
What drug treatment for Rheumatoid arthritis can cause pneumonitis?
methotrexate
What should you suspect in breathlessness and flail chest trauma?
tension pneumothorax
flail can create flap
- can result from trauma (incl. intubation + ventilation)
