Resp Flashcards
What is pleura made from?
a serous membrane of a single layered mesothelial cells & thin CT underneath
What is parietal pleura?
the inside part lining each hemithorax and continues with the visceral pleura at hilum of lung
What is visceral pleura?
lines the outside of lunges extending between lobes into the fissures
What is the BS of pleura?
Intercostal & internal thoracic arteries and veins
Innervation of pleura?
Parental pleura = somatic (intercostal & phrenic nerves) & autonomic
Visceral = no somatic, only autonomic
What is the pleural cavity/space?
potential peace between layers of pleura which is filled with fluid produced from the parietal space & absorbed by parietal lymphatic vessels
What is the function of pleural fluid?
allow the 2 layers to slide - allowing chest & lung moment in breathing
What is an important characteristic of the pleural fluid?
Surface tension - provides cohesion keeping lung surface in contact with thoracic wall so when thorax expands in inspiration, the lunch expands and fills with air along with it
Where is the apex of the lungs?
Above 1st rib, into the neck
Where is the base of lungs?
concave shape resting on diaphragm
How many lung lobes are there?
Left = 2 --> 1 fissure Right = 3 --> 2 fissure
What are the 3 surfaces of the lung?
costal, mediastinal, diaphragmatic
What are the names of the Right lobes and lung fissures?
Superior, middle & inferior lobes created b the right oblique & horizontal fissure
Left lung lobes and fissure?
superior and inferior lobes created by left oblique fissure
what is in the lung hilum?
bronchi, pulmonary arteries, superior & inf. pulmonary veins, pulmonary plexus of nerves and lymphatics
What is the pathway of the trachea?
Lower border of cricoid cartilage terminating into the Right and Left main bronchi at sternal angle
What shape cartilage are found in trachea?
c-shaped
What epithelium is the trachea?
pseudostratified ciliated columnar
what is the carina?
the angle between the the right & left main bronchi
what is the pathway of the airways?
Trachea> R main bronchus> lobar bronchi> segmental? bronchioles> terminal bronchioles>alveolar ducts> alveoli
What bronchus is shorter wider and more vertical?
the right main bronchus
What is the blood supply of the lungs from the heart?
1 Pulmonary A from pulmonary trunk
2 Pulmonary veins
What is the BS to the supporting lung structures?
Bronchial arteries coming from the Thoracic aorta
What is the mediastinum?
central compartment of the thoracic cavity
What is the mediastinum covered by?
the mediastinal pleura
what is contained in the mediastinum?
all thoracic viscera except lungs
Where is the heart and great vessels located?
the middle inferior mediastinum
What is important about the pulmonary circ. compared to systemic?
pulm. circ. must accept entire CO and work with low resistance as many capillaries in parallel and articles with little smooth muscles - so the circulation operates under a low pressure
What is the Boyle’s law?
Given amount of air is compressed into smaller volume, molecules hit more often so increase pressure.
Kinetic theory of gases?
gases move around a space and collide with walls to generate pressure. the more freq. and harder collisions, the more pressure
Charle’s law?
kinetic energy increases with temp
Universal gas laws?
calculation of volume when pressure and temp change
PxV = gas constant x Temp (kelvin)
What is the partial pressure?
in a gas mixture, it’s the proportion of pressure a particular gas gives
vapour pressure?
partial pressure of gas dissolved into evaporated water
saturated vapour pressure?
rate of molecules entering and leaving water
tension?
how readily gas leaves a liquid
Content of gas in liquid?
Solubility x tension
dissolving x readily leaving
Total gas content?
TC = reacted gas + dissolved gas
Total content of O2 in blood?
O2 bound to Hb + O2 dissolved in plasma
Tidal volume?
the volume of air breathed in and out in normal inspiration & expiration
Respiratory rate?
breaths per minute
What are the pulmonary circulations?
Pulmonary - to the alveoli for gas exchange, and bronchial - part of systemic to meet lungs demand
Key features of the pulmonary circulation?
Accepts all of CO
Low resistance as short, wide capillaries with many in parallel and the arterioles have little smooth muscles
Low pressure
What is ventilation: perfusion matching?
Efficient oxygenation requires the ventilation to the alveoli to be matched by the blood perfusion via pulm. circ.
The V/P ratio = 0.8
How to maintain the V/P ratio?
Hypoxic pulmonary vasoconstriction - to increases resistance so less flow which is instead diverted to well ventilated areas.
What is a complication of chronic hypoxic vasoconstriction?
Right ventricular failure as chronic increase in vascular resistance = after load on right ventricle causing failure
What is the upper resp. tract?
Above the thorax - nasal cavity, pharynx, larynx
What is the lower resp. tract?
Inside the thorax:
Trachea, Main bronchi, Lobar bronchi, segmental bronchi, bronchioles, terminal bronchioles, resp. bronchioles, alveolar ducts and alveoli
How many lobar bronchi are there?
3 on right
2 on left
Have cartilage in walls
Characteristic of bronchioles
No cartilage in walls and more smooth muscle than bronchi
Function of cartilaginous rings in trachea and bronchi?
To hold the airways open when moving neck
Characteristics of alveoli?
single cell thick
Short diffusion distance with Type 1 Simple Squamous cells
Type 2 cells release surfactant to reduce surface tension of alveoli
How do bronchioles draw air in?
Increasing volume by using smooth muscle in walls
What lines the conducting portion of the tract?
Mucous membranes containing goblet cells
What lines the pleural sacs enveloping the lungs?
Serous membrane
What is the epithelium for the upper tract, trachea and bronchi?
Pseudostratified, ciliated with goblet cells
What is the epithelium for the bronchioles and terminal bronchioles?
simple columnar with cilia and clara cells, no goblet cells
What is the epithelium for respiratory bronchioles and alveolar ducts?
simple cuboidal, clara cells and cilia
What is the epithelium of the alveoli?
Simple squamous
What are clara cells?
Cells that release surfactant to prevent the walls sticking together during expiration from surface tension.
Patient’s blood results indicates abnormal levels of protein CC16, what does this means?
High = leakage across air-blood barrier Low = lung damage
What is it important that there are no goblet cells in the terminal bronchiole?
Prevent person drowning in own mucus as very narrow airways
Describe terminal bronchioles?
no alveolar openings
Respiratory bronchioles?
some wall openings onto alveoli
Describe the alveolar duct?
duct wall with openings everywhere for alveoli
What is an alveolus?
a single alveoli
What is the alveolar sac?
air space onto which many alveoli open onto
Describe the structure of alveoli:
abundant capillaries
electric and reticular fibre network
covered in Type 1 pneumocytes - simple squamous
scattered Type 2 pneumocytes - simple cuboidal surfactant-releasing
macrophages lune the alveoli
Describe how lungs inhale air?
Lungs: bronchioles dilate to increase radius - lowering resistance, decreasing pressure within the lungs drawing air in.
Muscles: external intercostals elevate the ribs in bucket-handle movement (30%), and the diaphragm contracts to descend to increase the chest volume
Chest wall: expansion, and due to surface tension by pleural fluid, the lung parietal pleura follows taking the visceral pleura with it
What muscles are involved with quiet breathing?
I: Diaphragm and external intercostal
E: none (elastic recoil)
What muscles are involved in forced breathing?
I: diaphragm, Ext. I, scalee, pec minor, SCM, serrates ant
E: Internal & Innermost I, abo. muscles
What determines the rate of gas exchange?
Surface area - lots of alveoli
Resistance to diffusion
- short dd
- CO2 is more soluble, so diffuses faster so diffusion only changes O2 as it is limiting
Gradient of partial pressures
- air pushed in and out of alveoli by pressure differences through inspiration & expiration
What is Inspiratory reserve volume?
Extra volume that can be breathed in
What is Expiratory reserve volume?
extra air that can be breathed out
What is residual volume?
the volume left after max. expiration - only measured using helium diffusion, not a spirometer
What is vital capacity?
the max inspiration and max expiration
~5L
What is functional residual capacity?
volume of air in lungs are resting expiratory level ~2L
What is inspiratory capacity?
the biggest breath from resting expiratory level ~3L
Draw a spirometer trace
See picture
What is Serial/ Anatomical Dead Space?
same air entering and leaving airway. Last air in = last air out so not used in gas exchange
What is Nitrogen Washout test used for?
Measuring serial dead space
Describe the Nitrogen washout test
- Inhale 100% O2 - oxygen will mix with alveoli and will contain N2, but conducting airways will be just O2
- Exhale and measure % N2 in air expired
What is physiological dead space?
volume of air not taking part in gas exchange = anatomical dead space + alveolar dead space
How to measure alveolar ventilation rate?
about of air reaching the alveoli = Pulmonary vent rate - Dead space vent rate = RR(Tidal volume - dead space volume)
What is a pneumothorax?
integrity of the pleural seal is broken leading to the lung collapsing as air has entered between the 2 pleura layers so loss of fluid surface tension
What is lung compliance?
the stretchiness of the lungs (volume change per unit of pressure)
High lung compliance means…?
the lungs are easy to stretch
What type of compliance do stiff lungs have?
low compliance
What type of compliance do elastic lungs have?
high compliance
What factors affect compliance?
elasticity of the lungs
surface tension - resist stretching
What is the surface tension when lungs are deflated?
lower
What is the surface tension when fully inflated lungs?
high surface tension
What type of breathing is easier?
little breaths as it takes less force to expand small alveoli than larger alveoli
Explain laplace’s law:
Pressure related to radius of bubbles, so larger alveoli would eat smaller alveoli, but bigger alveoli have greater surface tension so surfactant is less effective. This pressure stops big alveoli eating small alveoli, so creates interconnecting set of bubbles with equal size.
Explain Poiseulle’s law:
resistance of tube increases with decreasing radius
Describe the level of resistance of small airways:
Whilst having a small radius, because they are parallel they have a low resistance so easy flow
What ‘work’ is done to inspire?
Work against the elastic recoil of the lungs and thorax to overcome the elasticity of lungs and surface tension forces of alveoli
Overcome the resistance to flow in the airways
What is Forced Vital Capacity?
maximum volume expired from full lungs
What is FEV1?
Forced expiratory volume in 1st second, speed of air flow - low if narrowed airways (COPD)
What is Restrictive disease?
Lungs are unusually stiff or inspiratory efforts are compromised by muscle weakness, injury or deformity.
What is the FVC and FEV1 in restrictive disease?
FVC reduced
FEV1 > 70% of FVC
(difficult to fill lungs, but air comes out normally)
What is Obstructive defect?
small airways are compressed so high flow resistance during expiration leading to no more air being driven out of alveoli. Expiratory flow compromised
What is the FVC and FEV1 in Obstructive defect?
FVC = normal
FEV1 = reduced
Lungs are easy to fill but hard to empty
What is measure in vitalograph?
Volume expired against time
What is measured in flow volume curves?
Volume expired against time, and Flow against Volume expired, taken from a vitalograph
What is PEFR?
Peak Expiratory Flow Rate - seen on flow volume curves, the exp. flow is max when lungs are full, airway are stretched and resistance is minimum
What happens to flow after PEFR?
Lungs compress are air leaving narrows the airways leading to increased resistance and decreased flow
What does COPD look like on flow volume loops?
Same PEFR, but rapidly dropping flow after & same total volume expired.
More severe COPD leads to reduced PEFR
What does Restrictive defect look like?
Normal PEFR, but smaller total volume expired (as less inspired)
What does fixed airway obstruction look like?
No peak, but level PEFR limited in height
What is helium dilution test used for?
Measuring Functional residual capacity which is used to calculate residual volume.
Helium = inert and can not diffuse across, known conc at start and new conc at end of normal exp. to calculate volume of lungs.
What is Carbon Monoxide transfer factor used for?
the rate of CO transfer from alveoli to blood measures how well gas diffusion is.
Tiny fraction of CO as is toxic
Solubility of water?
Not very soluble in water
Draw an oxygen-Hb dissociation curve:
ppO2 of lungs = 13.3kPa
ppO2 of tissues = 5kPa
Properties of Hb?
Reversible binding to O2
Tetrameric with 4 team groups so 4 O2 bind
Low affinity T-state when in tissues, high affinity R-state in lungs
sigmoidal binding curve = co-operative binding
O2 dissociation and temperature?
decreased affinity
O2 dissociation and low pH
decreased affinity
O2 dissociation and high CO2
decreased affinity –> Bohr Effect shift curve to the RIGHT
How does CO2 react in the blood?
Dissolved in water
reacting with water –> H+ & HCO3-
Binding to proteins –> carbamino compounds
CO2 mostly travels in the blood as HCO3-
What is Henderson-Hasselbach equation?
pH= 6.1 + Log ({HCO3-] / (pCo2 x 0.23))
What is the buffering effect of Hb?
Co2 reacts with water to produce H+ by carbonic anhydrase, which binds to Hb and pushes for more HCO3- production
What is hypoxia?
Low alveolar O2 leading to low arterial O2
Hypercapnia?
rise in alveolar, therefore arterial CO2
Hyperventilation?
Vent. increase without change in metabolism
What effect on pH does hyperventilation have?
Less CO2
Higher pH
What effect on pH does hypoventilation have?
More CO2
Lower pH
What are the effects of hypoventilation?
Respiratory acidosis and hypercapnia. Enzymes denature
What are the effects of hyperventilation?
Respiratory alkalosis and hypocapnia, free calcium conc falls as Ca only soluble in acid–> fatal tetany as nerves = hyper-excitable
What detects low pO2?
Peripheral chemoreceptors in carotid & aortic bodies. Fall in O2 supply to cells and only respond to large O2 drop.
How do the peripheral chemoreceptors respond to a fall in O2?
Increasing the tidal volume to increase rate of respiration - hyperventilate
Directing blood to kidneys & brain
Increasing HR and CO
How do peripheral chemoreceptors detect pCO2?
they don’t! dun dun duuuuuun!
What detects blood pCO2?
Central chemoreceptors in the medulla of the brain
Small rise in pCO2 > hyperventilation
How do central chemoreceptors work?
Art pCO2 = CSF pCO2 as CO2 transfers across the blood-brain barrier but HCO3- and H+ don’t.
CSF [HCO3-] are fixed by Choroid Plexus Cells, so pH rises with increased CO2 –> detected by Chemoreceptors so hyperventilate.
Persistently high CO2 –> CPC release more HCO3- to compensate therefore pH rises to normal but pCO2 remains high.
Respiratory failure is when..?
Art pO2 falls below 8kPa
What O2 saturation do clinicians aim for in T1RF?
94-98%
What are the signs of T1RF?
Central and peripheral cyanosis, SOB, confusion, cor pulmonale, excess RBCs
What are the signs of T2RF?
confusion, bounding pulse, headaches, flushing, CO2 retention flap
Why does T1 become T2 RF?
The muscles and cells fatigue so produce CO2 which is not adequately removed from the blood
What O2 saturation do clinicians aim for in T2RF?
88-92%
Treatments for T2RF?
Controlled O2, Non-invasive ventilation - mask
Causes of V/Q mismatch?
Ventilation problems = asthma
Perfusion problems = PE, pulmonary hypertension, R–>L shunt like patent foramen ovale
Causes of diffusion failure?
Liquid: pulmonary oedema and pneumonia
Structural: Emphysema (LESS SA) and fibrosis (THICKER)
Affects O2 not CO2
Causes of alveolar hypoventilation?
Obstructive: COPD, asthma
Restrictive: Obesity, fluid, fibrosis, chest wall problems, kyphosis, pneumothorax, Neuromuscular problems - resp. depression in opiate OD, head injury, muscle weakness
Causes for reduced O2 carriage by Hb?
Anaemia
What does a pulse oximeter measure?
the % saturation of O2 in Hb
What does ABG measure?
amount of dissolved O2 in blood
Consequence of chronic hypoxia?
Increased Erythropoietin production & increased vent.
Chronic hypercapnia?
The Choroid Plexus cells release HCO3- to compensate for high CO2, hence hypoxia drives ventilation
Key features about asthma?
Chronic, reversible airflow obstruction, characterised by inflammation and re-modelling of airway walls.
Triggers: cold, exercise, pollen, dust
It is treated with bronchodilators - salbutamol
What is the pathophysiology of Asthma?
Acute - T1H, IgE mediated, mast cell release of histamine and prostaglandins
Chronic - T4H, TH2 cells release cytokines and leukotrienes to stimulate mast cells and eosinophils.
Asthma gives thicker smooth muscle and basement membranes (deposit collagen) > reduce radius > increase resistance > reduce flow
Goblet cell hypertrophy > dry cough
Causes of asthma?
Genetic risk
Atopy: smoke, pollens, pollution, dust mites, fungus (aspergillus)
Stress: cold, exercise, viral URTI
Toxins: beta blockers, NSAIDs
Clinical presentation of Asthma?
Wheeze - expiratory sound that varies intensity & tone (polyphonic)
Dry cough - worse at night, excrete induced
SOB - esp. with exercise
Chest tightness
Airflow obstruction (entry)
Hyper-resonant percussion of chest as lungs = hyper inflated
Patient using accessory muscle to breathe
Hyper inflated chest / barrel chest
Increased RR
What investigations do you do fro asthma?
Bedside: Sputum MC&S Peak flow Bloods: eosinophilia, CRP Imaging: CXR - hyperinflation Atrophy: skin prick test
Spirometry - obstructive pattern:
FEV1 improves by 20% using salbutamol - bronchodilator reversibility
Causes of asthmatic attacks?
X Tx adherence
Viral URTI
Allergens & triggering drugs (NSAIDs)
Treatment for Asthma?
Education, prevention. drugs - B2-adrenoagonist - Salbutamol, anti-inflammatory - corticosteroids
Obstructive airway conditions?
COPD, Asthma, lung cancer, bronchiectasis
Constrictive airway conditions?
Pulmonary fibrosis
Kyphosis, scoliosis, NMD - brain, MS; obesity, pneumothorax
What is COPD?
Chronic and slow-progressing airway obstruction, not fully reversible. Mostly caused by smoking.
Pathophysiology of COPD?
Chronic Bronchitis: - chronic inflammation of bronchioles leading to fibrosis of airways and mucous gland hyperplasia
Emphysema: - destruction of alveolar walls leading to reduced SA for gas exchange and reduced expiratory volume. Often caused by smoking
Clinical features of COPD?
Wheeze, SOB, cough with white sputum, weight loss
Signs of COPD?
High RR, hyper-resonant and hyper inflated chest, cor pulmonate (raised JVP and Pulmonary oedema), barrel chest, obstructive breathing
Causes of COPD?
Smoking
A1AT deficiency - young and genetic
Industrial pollutants
Test for COPD?
Bedside: MC&S of white sputum
Bloods: FBC - raised RBCs, a1AT deficiency, ABG
Spirometry: Obstructive defect and FEV1 used to gage severity
CXR: hyperinflation, flattened diaphragm, bulla (air pocket), pulmonary vessel enlargement
Treatment for COPD?
Conservative: stop smoking, pulmonary rehab - exercise training to increase capacity to
Meds: bronchodilators - salbutamol
steroids as prevention
mucolytics - reduce mucus production
Abi for infections
O2 therapy - but non-smoking and not pO2 dependant for ventilation
Surgical- lung volume reduction
How do you assess the impairment from COPD?
MRC Dysponea scale: 1-5
1 being no trouble except breathlessness from strenuous exercise to 5- total breathlessness when dressing/unable to leave house
What are the natural defences of the resp. tract against infection?
Mucus - traps bacteria
Cilia wafts them to the back of the throat to be swallowed
Sneezing & coughing reflex
Lymphoid tissue of pharynx, alveolar macrophages and secretory IgA and IgG
What do URTI affect?
Nose, pharynx, epiglottis, larynx, sinuses and middle ear
Viral causes of URTI?
Rhinovirus
influenza
Bacterial causes of URTI?
Streptococcus pneumonia,
Haemophillis Influenza
Morexella
Common URTI?
Rhino sinusitis and otitis media –> mastoiditis, meningitis and brain abscesses
What is pneumonia?
a LRTI, inflaming the alveolar surfaces responsible for gas exchange and producing exudate
Lobar pneumonia is..?
Pneumonia affecting a particular lobe caused by strep. pneumonia
Bronchopneumonia is?
Diffuse and patchy - starting in airways and spreads to alveoli
Aspiration pneumonia?
Aspiration of food, drink or vomit leads to pneumonia
Interstitial pneumonia?
Inflammation of intersticium of lungs - epithelium, capillary end, BM
Chronic pneumonia?
Persisting inflammation of the LRT over a long period of time
How does pneumonia appear on a CXR?
consolidation - pus, cellular fluid
Most common cause of community acquired pneumonia?
Strep. pneumoniae
Haemophilus influenza
Atypical: chlamydia pneumophilia
Most common causes of hospital acquired pneumonia?
Pseudomonas aeruingosa, staphylococcus aureus, e.coli
Aspiration - stroke/elderly
Immunocompromised: TB, HSV, CMV, PCP
Symptoms of pneumonia?
Productive cough - purulent, heamoptysis
Pleuritic chest pain
SOB
Fevers, rigors
Signs of pneumonia?
Increased RR and HR Fever Cyanosis Confusion Consolidation - reduced expansion, reduced air entry, dull precision, bronchial breathing, crackles, reduced vocal resonance
What is CURB-65?
C = confusion
U- urea >7mmol/L
R- RR>30
B = blood pressure 65
CURB 1 = mild, 2=moderate & hospital, 3+ = severe
Investigations for Pneumonia?
Bedside: MC&S of sputum Urine for Ig - legionella Blood: FBC, U&Es CRP, LFTs, ABG & cultures - PCR viruses, serology
Imagining - CXR for consolidation & abscesses
Tx for pneumonia?
Depends on CURb-65
Community: Amoxicillin & Doxycycline
Hospital: Co-amoxiclav
IV fluids, anti-paretics, analgesia, O2
Outcomes of pneumonia?
Resolution
Pleural effusion & empyema
Abscesses
Septic shock
Prevention of pneumonia?
Immunisation for flu
Prophylaxis - oral penicillin for asplenia, IC
What atypical bacteria is responsible for TB?
Mycobacterium tuberculosis
How is TB spread?
aerosol spread through droplets and coughs
What does TB form on the pleural space?
Ghon focus
TB involvement with the lymph nodes is called a..?
Ghon complex
Primary TB symptoms?
Asymptomatic
Primary Progressive TB?
TB spread extrapulmonry and military spread (throughout body) via lymphohaematogenous system
Outcomes of TB?
Spontaneous resolution or localised infection - e.g. meningitis
Military Tb?
widespread dissemination throughout body by bloodstream - primary or in reactivation. can causes retina involvement or ascites
Dormant TB?
Infected, but TB is not expressing clinical or CXR signs. Will reactivate when weakened immune resistance
Pathology of TB?
MB injected by macrophages which escape the phagolysosomes and multiply in the cytoplasm. The intense immune response causes destruction of local tissue –> cavitation of lungs & granuloma formation, and systemic cytokine-mediated effects - weight loss & fever
Clinical presentation of primary TB?
Initially few symptoms - enlarged LNs
Post-primary:
Chronic cough, heamoptysis, fever, night sweats, weight loss and recurrent bacteria pneumonia
Tuberculosis meningitis presentation?
Fever, headaches and deteriorating level of consciousness
Common sites of TB infection?
Meninges,
kidneys,
lumbosacral spine - vertebral collapse and nerve compression
Large joints - destructive arthritis
Signs of TB?
Pleural effusion - deviated trachea, stony dull percussion, reduced vocal resonance
CXR: shadowing, cavities, consolidation, cardiomegaly, military seeds
Tuberculosis spondylitis?
Osteoarticular TB - affecting vertebral bones
TB risk factors?
history of TB TB contact born in country with high TB prevalence foreign travel immunosupression
Investigations?
3 Sputum cultures - acid fast, MC&S, PCR
Bloods: FBC, CRP, LFTs, HIV test
Imaging:
CXR, MRI if suspect military TB spread
Diagnostic tests for TB?
Quantiferon test
Measures IFN-Y production after patient lymphocytes incubated with TB antigens
TB Tx?
2 months RIPE R = rifampicin I = isoniazid P= pyrazinamide E = ethambutol
4 months of RI
Rifampicin & isoniazid
Why so many TB medications?
Reduce resistance, Directly Observed Therapy
Preventing TB?
BCG vaccine = attenuated liver Bovine TB
Public health regulations about TB?
Notifiable disease
Contact tracing - 3 months prior
Isolation in hospital
DOT if uncomplient/homeless
TB is associated with..?
HIV
Overcrowding
Asians
Malnutrition
What is Bronchiectasis?
chronic infection of bronchioles and bronchi - causing permanent airway dilatation and retention of inflammatory secretions leading to recurrent infections
Causes of bronchiectasis?
Congenital - CF
Post-infection - TB, pneumonia, Whooping cough
Inflammatory - RA, UC
Symptoms of Bronchiectasis?
Purulent cough
haemoptysis
fever
weight loss
Sign of Bronchiectasis?
clubbing
wheeze
fine inspiratory crepitus
investigations of bronchiectasis?
Sputum MC&S
Bloods - FBC, immunology, blood cultures
Imaging - CXR - thickened bronchiole walls, hyper inflated lungs
Spirometry & CT sweat test (measuring level of chloride in sweat)
Bronchiectasis Tx?
Chest physio
ABx - 14 days co-amoxiclav and flucloxacillin
Bronchodilators
What is pleural effusion?
build up of fluid in pleural space between lungs and chest wall
Risk factors for lung cancer?
Smoking
Age
FHx
Exposure to radiation or asbestos
Types of lung cancers?
Small Cell Carcinoma - presents late and mets early Non-small cell: Squamous cell Adenocarcinoma Large cell
Clinical features of lung cancer?
SOB Chronic cough with heamptysis Hoarseness Weight loss Fatigue chest pain
Signs of lung cancer?
clubbing supraclavicular/axillary LNs anaemia, Horners Pleural effusions
Investigations for Lung cancer?
Bloods - FBC, U&Es, Lung function test, bone profile
Imaging:
CXR, staging CT (TNM), PET-CT as detects mets
Biopsy - bronchoscopy, thoracoscopy
Pleural fluid aspiration
Lung function test
Complications of LC?
Local: recurrent laryngeal nerve palsy, phrenic nerve palsy, SVC obstruction, AF, Horners syndrome
Distant:
mets to bone
compression of VC - weak legs, back pain, loss off sensation, NM problems
Liver - hepatomegaly
Brain - confusion
Adrenal gland - addison’s
Paraneoplastic: MSK - clubbing Peripheral neuropathy Anaemia Endo: Raised Ca - PTHrp SIADH Cushings - ATCH
LC Tx?
Curative vs Palliative
Surgery
Chemo
Radio
Stages of LC?
1 - small, localised to 1 area
2&3 - larger and growth to LNs
4 - distant metastasis
TMN of LC?
T1 - within lung 1 cancer in same lobe
N0 - no LNs
N1 - nearest node
N2 - same side of mediastinum
N3- opposite side/supraclavicular
M0/1
How to obtain a biopsy of lung?
Bronchoscopy with needle or surgical biopsy
What type of LC is worse?
Small cell
What causes pleural effusions?
Exudate from increased capil. permeability - cancers, pneumonia, TB, inflam. (RA, SLE)
Transudate: increase hydro. or reduced oncotic pressure
PE, HF, CKD, liver failure
Investigations for pleural effusions?
Bloods: FBC, U&Es, LFT, CRP
CXR: blunt costophrenic angle, meniscus sign, mediastinal shift
US-guided pleural aspirationL colour, biochem (pH LDH, proteins, glucose), cytology, microbiology,
What are different types of pleural effusions?
Haemothorax - blood
Empyema - pus
Chylothorax - lymphatic fluid
Simple effusion - serous fluid
What are interstitial lung diseases?
disorders affecting lung parenchyma (between capillaries and alveoli) - contains fibrous tissue, cells of fluid
Causes of ILD?
Occupation - asbestos, silica Iatrogenic - methotrexate, chemo Inflammatory - RA, SLE Idiopathic Infection - TB
Symptoms of ILD?
SOB Progressive dry cough Coarse inspiratory crackles Abnormal CXR - shadowing Restrictive spirometry
Investigations for ILD?
Bloods - FBC (eosinophilia), immunology, CXR, spirometry
ILD Tx?
Underlying cause High dose steroids O2 therapy analgesics X smoking
Talk about asbestos exposure?
Causes asbestosis, mesothelioma, pleural plaques, pleural thickenings, pleural effusions
Mesothelioma signs?
Chest pain, weight loss, SOB, recurrent pleural effusions
CXR - pleural effusions, thickenings
Pleural biopsy
What is extrinsic allergic alveolitis?
exposure to inhaled allergen causing reaction.
Inspiratory crackles
wheeze
No finger clubbing
Micro nodules
Acute - sudden onset within hours, reversible spont. / with tx
Chronic - less reversible
Causes of allergic alveolitis?
bird fanciers - droppings
mouldy hay with farmers - aspergillus
What is a pneumothorax?
air trapped in pleural space - associated with trauma
What is a tension pneumothorax?
tracheal shifts AWAY from pneumothorax
CXR - calcified plaques?
Asbestos exposure
Hyperinflation?
COPD - blunting of costophrenic angles and hemidiaphragms
Pneumoperitoneum?
Bowel perforation with air seen under the diaphragm
CXR - cardiomegaly?
Over 50% the width of the thorax (measuring from widest past of heart and ribcage laterally)
Why is it harder to breath with ILD?
Fibrosis is restrictive deficit, resistance not increased, lengthened diffusion pathway
What is fibrosis alveolitis?
Progressively inflammatory condition - activated alveolar macrophages attracting neutrophils and eosinophils, damaging lung with proteases and ROS leading to fibrosis.
Finger clubbing, SOB, non-productive cough, micro-nodules on CXR.
Tx - high dose steroids
What is sarcoidosis?
non-caseasting granuloma idiopathic fluid in always and lots of cells in the alveoli diffuse fibrosis genetic predisposition Features - asymptomatic, cough & SOB Tx - steroids
What is pleurisy/ pleuritis?
Inflammation of pleura
Signs of pleurisy?
Sharp pain on inspiration and pleural rub - creaking noise in steph. with resp. movements
Causes of pleurisy?
Infection - TB, pneumonia
Autoimmune - SLE, RA
Lung cancer
Pneumothorax
PE
Chest wall abnormalities?
scoliosis
kyphosis
broken ribs –> pneumothorax
Muscle and neuro disease?
Muscular dystrophy
Motor neurone disease
polio
At risk of resp. failure, and infections
