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ESA 3 > Resp 7 > Flashcards

Resp 7 Flashcards

1
Q

List some of the common microbial flora in the Upper respiratory tract (URT)

A

Common permanent colonies:

Viridans streptococci

Neseria spp.

Anaerobes

Candida sp

Common transient colonies:

Streptococcus pneumoniae

Strep pyogenes

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2
Q

List the specific defenses of the respiratory system against infection

A

Muco-ciliary clearance:

Nasal hairs, ciliated columnar epithelium

Cough and sneezing reflex

Respiratory mucosal immune system:

Lymphoid follicles in the pharynx and tonsils, alveolar macrophages, secretory IgG and IgA

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3
Q

Give examples of URT infections

A

Rhinitis (Common cold)

Pharyngitis

Epiglotitis

Laryngitis

Tracheitis

Sinusitis

Otitis media

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4
Q

What are the common features of URTIs?

A

Most commonly causes by viruses:

Rhinovirus

Coronavirus

Respiratory syncytial virus (RSV)

Can lead to bacterial superinfection:

Esp. Sinusitis and otitis media

Can lead to mastoiditis, meningitis, brain abscess

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5
Q

What are the two common forms of Lower respiratory tract (LRT) infections?

A

Bronchitis

Pneumonia

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6
Q

Differentiate aetiology of acute and chronic bronchitis

A

Acute:

Viruses and bacteria

May lead to pneumonia

Chronic:

Not primarily infective

Exacerbations can be infective

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7
Q

Give a brief description of pneumonia

A

Infection of pulonary parenchyma:

Involves distal airspaces and results in inflammatory exudate

Fluid filled air spaces and consolidation lead to heavy, stiff lungs

Gas exchange impaired resulting in local and systemic effects

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8
Q

By what methods might we classify pneumonia?

A

Clinical setting (Hospital, community)

Presentation (acute, sub-acute, chronic)

Organism (bacteria, fungi, viral)

By lung pathology (lobar, broncho- or interstitial pneumonia)

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9
Q

What is pneumonitis?

A

Non-infective inflammatory disease of lung parenchyma

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10
Q

Give examples of common and atypical bacteria implicated in pneumonia

A

Common:

S. pneumoniae

H influenzae

Kleb pneumoniae

Atypical:

Chlamydia spp.

Mycoplasma

Legionella

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11
Q

Give examples of common viruses implicated in pneumonia

A

Influenza

Parainfluenza

RSV

Adenovirus

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12
Q

Give examples of common microbiota implicated in:

    • Hospital acquired pneumonia*
    • Aspirational pneumonia*
    • Pneumonia in immunocompromised host*
A

Hospital:

G-neg enteric bacteria

Pseudomonas

S aureus and MRSA

Aspirational:

Anaerobes and oral flora

Immunocompromised host:

Candida sp

Aspergillus

Viruses (HSV, VZV)

Pneumocystis jirovecii

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13
Q

What are some patient features associated with S pneumoniae infection?

A

Elderly

Co-morbidities

Acute onset

High fever

Pleuritic pain

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14
Q

What are some patient features associated with H influenza infection

A

COPD

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15
Q

What are some patient features associated with Legionella infection

A

Recent travel

Infected aerosol exposure

Smokers

Young

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16
Q

What are some patient features associated with Mycoplasma infection

A

Young

Prior antibiotics

Extra-pulmonary involvement (haemolysis, skin and joints)

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17
Q

What are some patient features associated with S aureus infection

A

Post viral

People who inject drugs (PWID)

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18
Q

What is lobar pneumonia?

A

Confluent consolidation involving a complete lung lobe

Most often due to Strep pneumoniae

Usually community acquired

Acute onset

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19
Q

Describe the pathology of lobar pneumoniae

A

Disease:

Acute inflammatory response

Exudation is fibrin rich fluid

Neutrophil and macrophage infiltration

Response:

Resolution due to immune system

Antibodies opsonise and lead to phagocytosis of bacteria

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20
Q

What is broncho-pneumonia?

A

Infection starting in the airways and spreading to adjacent alveoli and lung tissue

Most commonly seen in context of pre-existing disease

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21
Q

What might be the causes of broncho-pneumonia?

A

Complication of viral infection (influenza)

Aspiration of gastric contents

Cardiac failure

COPD

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22
Q

Describe the appearance of broncho-pneumonia when viewed radiologically

A

Pathy infiltrates that are not confined to lobar architecture

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23
Q

List the typical organisms causing broncho-pneumonia

A

Srep pneumoniae

H. influenza

S. aureus

Anaerobes

Coliforms

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24
Q

What is the treatment for typical acute bacterial pneumonia?

A

Amoxicillin (Mild to moderate)

Co-amoxiclav (severe)

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25
Q

What are the possible outcomes of acute bacterial pneumonia?

A

Resolution

Organisation of tissue (Fibrous scarring)

Complications:

Lung abscess

Bronchiectasis

Empyema

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26
Q

Describe the investigations and appearance of atypical pneumonia

A

Investigations:

Sputum stain and G culture

CXR

Urine antigen test (legionella)

Bllod testing for antibodies

Appearance:

Unilateral/bilateral path segmental infiltrates (usually lower lobes)

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27
Q

Describe the typical causative organisms and treatment for atypical pneumonia

A

Organisms:

Chlamydia pneumoniae

Mycoplasma pneumoniae

Legionella pneumoniae (Notifiable)

Treatment:

Levofloxacillin, Erythromycin, Clarithromycin, Doxycycline

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28
Q

Describe the pathology and appearance of viral pneumonia

A

Pathology:

Damage to cells lining the airways/alveoli by the virus and immune cells

Fluid fills air spaces and interferes with gas exchange

Severe forms can lead to necrosis/haemorrhage into lung parenchyma

Appearance:

Patchy or diffuse

Ground glass opacity on CXR

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29
Q

What is the definition of hospital acquired pneumonia?

In who is it most common?

A

Pneumonia occuring 48hrs post-admission

Most common in ITU, post surgical and ventilated patients

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30
Q

What organisms are the likely causes of HAP and how is it treated?

A

Organisms:

Enteric Gram-neg bacteria (E. coli)

Pseudomonas

Anaerobes

S aureus/MRSA

Treatment:

Broad spectrum antibotics

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31
Q

What conditions predispose aspirational pneumonia?

What are the at risk groups for aspirational pneumonia?

A

Predisposing conditions:

Alcoholism
Dsyphagia
Epileptics
Drowning

Risk groups:

Eldery in care homes
Drug takers

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32
Q

What are the symptoms of pneumonia?

A

Fever, Chills, Sweats, Rigor

Cough

Purulent/Rust-coloured sputum

Dyspnoea

Pleuritic chest pain

Maliase, Anorexia, Vomiting

Headache

Myalgia

Diarrhoea

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33
Q

What are the specific chest signs of pneumonia?

A

Bronchial breath sounds

Crackles

Wheeze

Dullness to percussion

Reduced vocal resonance

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34
Q

List the non-microbiological investigations for pneumonia

A

CXR

O2 sats and ABG

FBC, WBCC, Platelets

Urea, LFT and CRP

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35
Q

What are the useful markers in assessment of pneumonia disease progression?

A

WBCC:

>20 or <4 indicate severe disease

CRP:

Assessment of response to treatment

Radiology:

Reliable

Radiological signs can very rarely lag behind clinical characteristics (24-48hrs)

36
Q

What are the microbiological samples that might be taken during diagnosis/treatment of pneumonia?

A

Sputum

Nose or throat swabs

Endotracheal aspirates

Broncho-alveolar lavage fluid

Open lung biopsy

Blood culture

Urine (Detect legionella antigens)

Serum

37
Q

What are the microbiological investigations into pneumonia?

A

Macroscopy (Mucoid, purulent, blood stained)

Microscopy (Gram stain, acid fast, special stains)

Culture (Bacteria and virus)

PCR (respiratory virus ID)

Antigen detection (Legionella in urine)

Antibody detection (serology)

38
Q

What is the CURB-65 prognostic index?

A

Used to assess severity of pneumonia

Criteria:

Confusion (AMT <8)
Urea - >7
RR - >30
BP - <90s or <60d
Age - >65

Add 1 point if yes to any of these

If score is >2 then admission +/- ITU referal advised

39
Q

What are the principles of pneumonia treatment?

A

Assess severity and co-morbidities

Give supportive and specific treatment

Broad spectrum antibiotics to cover most organisms

Review patient if change in microbiology resuts or poor response

Follow local guidelines

40
Q

Describe the antibiotic treatment of pneumonia

A

1st line:

Penicillin class antibiotics (Amoxycillin)

Severe infection:

Penicillin class + Clavulanic acid (Co-amoxiclav)

Legionella pneumonia:

Levofloxacin

Other atypical organisms:

Tetracyclines or macrolides

Poor response:

Discuss with microbiology

41
Q

Describe pneumonia prophylaxis

A

Immunisation:

Flu vaccine - annual to high risk patients

Pneumococcal vaccine (2 vaccines)

Chemoprophylaxis:

Oral penicillin/erythromycin to high risk patients (i.e asplenia, immunodeficient)

42
Q

In what circumstances should you refer to ITU in a patient with pneumonia?

A

CURB-65 of >2

Respiratory failure occurs

Rising pCO2

Worsening metabolic acidosis

Hypotension despite fluid resus

Query patient suitability for ITU (E.g. If ITU treats successfully will there be any quality of life?)

43
Q

What special measures must be taken in the dignosis of pneumonia in the immunocompromised host?

A

High index of suspicion

Multidisciplinary involvement

Broncho-alveolar lavage and lung biopsies as a more standard method of histological diagnoses (lots of special stains!)

44
Q

List the likely causes of pneumonia or LRTIs in a cystic fibrosis patient

A

Early infections:

H influenza

S aureus

Later:

Pseudomonas aeuruginosa

Burkholderia cepecia

45
Q

What is the common causative organism of pneumocystic pnumonia?

Who are at risk for this infection?

A

Organism:

Penumocystis jirovecii

Risk groups:

HIV infected

Transplant recievers

Immunocompromised

46
Q

How is diagnosis of Pseudomonas jirovecci infection made?

What is the reccomended treatment?

A

Diagnosis:

Induced sputum, broncho-alveolar lavage and lung biopsy used to determine diagnosis histogogically

PCR can be used to confirm P jirovecii

Treatment:

High dose Cotrimoxazole

47
Q

What is Whooping cough?

What are the symptoms?

A

What:

Disease of respiratory tract caused by Bordetella pertussis

Symptoms:

Starts off cold-like

Progresses to characteristic ‘whoop’ or vomiting

Can last 2-3 months

48
Q

Who is at greatest risk of Whooping cough?

How is it spread?

A

High risk:

<1 year

Transmission:

Droplets

49
Q

Outline the clinical management of whooping cough and prevention of whooping cough

A

Diagnosis:

Specimens (Nasal or nasopharyngeal swbs or aspirates)

Culture/PCR

Treatment:

Erythromycin

Prevention:

Childhood vaccination

Vaccination of pregnant mothers

50
Q

What is the incidence rate of lung cancer and related mortality in the UK?

A

37,500 new cases per year

33,000 deaths per year

51
Q

Smoking causes what proportion of lung cancer in:

    • Male smokers*
    • Female smokers*
    • Non smokers*
A

90%

80%

20%

52
Q

What proportion of cancer deaths are attributable to smoking?

A

1/3

53
Q

What are some risk factors for lung cancer other than smoking?

A

COPD (3-6x relative risk)

Asbestos

Radon gas exposure (mining or indoor exposure)

Occupational carcinogens (Chromium, nickel, arsenic)

Genetic/familial factors

54
Q

How is Lung cancer distributed over socio-economic groups?

A

Higher prevalence in the poorer:

40 per 100,000 in affluent

100 per 100,000 in poorest

Age standardised

55
Q

What are the symptoms of a primary lung tumour?

A

Cough

Dyspnoea

Wheezing

Haemoptysis

Chest/Shoulder pain

Weight loss

Lethary/Malaise

56
Q

What are the possible symptoms of a region lung cancer metastases?

A

Superior vena caval obstruction

Hoarseness (Left reccurent laryngeal nerve palsy)

Dyspnoea (Phrenic nerve palsy)

Dysphagia

57
Q

What are some of the possible symptoms of distant lung cancer metastases?

A

Bone pain/fracture

CNS symptoms (Headache, double vision, confusion)

58
Q

List the range of paraneoplastic syndromes possible in lung cancer

A

Endocrine:

Hypercalcaemia

Cushings

SIADH

Neurological:

Encephalopathy

Peripheral neuropathy

Haematological:

Anaemia

Thrombocytosis

Skeletal:

Clubbing

59
Q

Where are the common sites of metastases for lung cancer?

A

Local:

Draining nodes

Pleura

Pericardium

Distant:

Brain

Liver

Adrenals

Bone

60
Q

How is lung cancer first investigated then diangosed and staged?

A

On first clinical suspicion:

Plain CXR

Diagnosis and staging:

Serum biochemistry (Na+, LFT, Ca2+)

Imaging (CT and PET CT, Isotope bone scan)

Tissue:

    • Endobronchial ultrasound*
    • CT guided biopsy of lung*
    • Biopsy of lymph nodes, pleura and metastatic sites*
61
Q

What are the major cell types in lung cancer?

A

Carcinoma:

Non-small cell carcinoma: ~80%

    • Squamous cell carcinoma* ~40%
    • Adenocarcinoma*
    • Large cell carcinoma*

Small cell carcinoma ~12%

Rare tumours (E.g. Carcinoid) ~5%

62
Q

Describe squamous cell carcinoma

A

Often central tumours

Angulate cells

Eosinophilic cytoplasm

Keratinisation

Intercellular bridges

Keratin pearls

63
Q

Describe adenocarcinoma

A

Often peripheral tumour

Columnar/cuboidal cells

Form acini (glands)

Papillary structures

May line alveoli

Some produce mucin

64
Q

Describe small cell carcinoma

A

Very cellular tumour

Small nuclei

Little cytoplasm

Nuclear moulding

Often necrosis and lots of mitoses

65
Q

Describe the local effects of cancer within the lung

A

Necrosis +/- cavitation

Ulceration (haemoptysis)

Infection (abscess formation

Bronchial obstruction, lung collapse, consolidation

66
Q

Describe the effects of spread of lung cancer within the thorax

A

Direct spread or metastasis to pleura/pericardium

Pleural/pericardial effusions

Compression of structures (Superior vena caval obstruction, dysphagia)

Reccurent laryngeal nerve might be effected (Hoarseness)

Phrenic nerve might be affected (Diaphragm palsy/dyspnoea)

67
Q
A
68
Q

What is the role of imaging in lung cancer?

A

Extensive use through clinical experience

Screening

Diagnosis, staging, trreatment planning

Assessing response to treatment

Assessing complications

Aiding interventions

Checking for recurrence

69
Q

How is lung cancer staged?

A

TNM staging I - IV

70
Q

Describe the difference between a stage I and Stage IV primary lung tumour

A

TI:

<3cm diameter, operable

TIV:

Large, usually inoperable lung mass

Invades into surrounding structures (Trachea, pleura, bronchi, mediastinum, great vessels)

71
Q

Describe nodal staging in lung cancer

A

Nodes with short axis diameter of >10mm considered abnormal

Where abnormal nodes appear determines stage

NI:

Peribronchial

Ipsilateral hilar

N2:

Ipsilateral mediastinal

Subcarinal

N3:

Contralateral mediastinal

Contralateral hilar

Scalene

Supraclavicular

72
Q

Describe metastases staging in lung cancer

A

M0:

No metastases

M1a:

Lung nodules, pleural effusion

M1b:

Distant metastases

73
Q

What radiological investigations would you perform to find/assess bone metastases

A

X ray

Scintigraphy

74
Q

Describe scintigraphy of bone and how it’s useful to visualising bone metastases

A

Scintigrpahy:

Radioiostopes administered and prefferentially taken up by bone

Greatest concentrations will be in areas of greatest cellular activity

Radiation detected by external cameras

Use:

Metastases will appear as areas of bone with higher than normal activity and hence darker

75
Q

What is the role of ultrasonography in lung cancer?

A

Guided biopsy (Lung, liver, ribs, peripheral lesions)

Identification of pleural effusion

Identification of chest wall invasion of tumour

76
Q

What is the role of stenting in lung cancer?

A

Primary tumours or local metastases can compress and obstruct flow through structures, stenting alleviates this

E.g. Superior vena cava obstruction stenting or airway stenting

77
Q

What is the role of MRI in lung cancer?

A

Identification of metastases

78
Q

What is FDG PET?

A

FGD is a glucose analogue with a Flourine-18 atom attached

FDG taken up into cells as a marker for glucose uptake

Increased FGD uptake therefore indicates metabolic rate

Flourine 18 emits positrons to allow this to be visualised in a PET scanner

79
Q

What are overall 5 year and median survival rates for lung cancer?

What factors influnece prognosis?

A

5 yr survival:

10-15%

Median:

6 months

Prognosis:

Cell type

Stge

Performance ststus (General fitness)

Biochemical markers

Co-morbities

80
Q

What is the most coomon routes to diagnosis for pateints?

A

Emergency presentation (~40%)

Screening (~20%)

81
Q

How does route to diagnosis affect survival rates?

A

Emergency presentation has a 12% survival rate at 1 year

Screened, two week waiters, GP referral or other outpatients have 40% survival at 1 yr

82
Q

What are the treatment options for lung cancer?

A

Surgery:

Normally non-small cell (20-25% operable)

Radiotherapy:

Either radical (potentially curative) or palliative (Symptom control

Combination chemotherapy:

Small cell is potentially curative

Non-small cell gives modest survival increase and symptom control

Combination therapy:

Chemo-radiotherapy (potentially curative)

Biological therapies

Palliative care

83
Q

Describe non-small cell lung cancer management

A

Multimodality therapy

Palliative radiotherapy:

For local symptom relief and bony metastases symptom relief

Chemotherapy:

50-60% response rates, modest survival improvement, can be cell type targeted

Combination Chemo-radiotherapy:

Important in locally advanced disease

Targeted agents:

Epidermal growth factor inhibitors

ALK inhibitors

Immunotherapy

84
Q

Describe small cell lung cancer management

A

Systemic and rarely operable disease with ~3 month survival untreated

Treatment focus is therefore palliative

85-90% respond to combination chemo, gives approx 1 year added survival if combined with radiotherapy in early stage disease

Death from cerebral metastases common

85
Q

What and who is involved in supportive treatment for lung cancer?

A

Focuses on prompt treatment of symptoms

Palliative care involvement from early stage

Nurse specialists have a central role

Specific palliation best done by appropriate clinician for symptoms

86
Q

What are the problems with lung cancer management and attempts to treat?

A

Late diagnosis common

Poor prognosis

Very symptomatic

Professional nihlism

Variable standards of care

Lack of public pressure for improvement

87
Q

What are the effects of public health campaigns and screening regarding lung cancer?

A

E.g. 3 week cough campaign

Reduced incidence of death from lung cancer in those screened

Shift towards earlier stage diagnosis

ESA 3 (54 decks)

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