Resp Flashcards
1
Q
What is COPD?
A
A common progressive disorder characterised by airway obstruction with little or no reversibility
2
Q
What is chronic bronchitis?
A
Cough and sputum production on most days for 3 months of 2 successive years, improves with smoking cessation
3
Q
What is emphysema?
A
Enlarged air spaces distal to terminal bronchioles, with destruction of alveolar walls
4
Q
Epidemiology of COPD
A
Male, >35yrs
5
Q
Risk factors for COPD
A
Smoking, occupational dust and chemicals, environmental tobacco smoke (ETS), indoor and outdoor air pollution, genes, infection, socio-economic status
6
Q
Pathophysiology of chronic bronchitis
A
o Blue bloaters
o Bronchial wall inflammation and mucosal oedema ->
airways narrow -> body increases perfusion (CO) ->
V/Q mismatch -> hypoxia (blue)
o Obstruction -> increasing residual lung volume ->
bloating
7
Q
Pathophysiology of emphysema
A
o Pink puffers
o Destruction of lung tissue distal to terminal
bronchioles -> loss of elastic recoil -> air trapping
o Damage to capillary bed -> inability to oxygenate ->
hyperventilation (puffing)
8
Q
Signs of COPD
A
o Raised respiratory rate
o Hyperexpansion/barrel chest
o Cyanosis
o ‘Cor pulmonae’ – HF, oedema
9
Q
Symptoms of COPD
A
o SOB
o Cough, phlegm
o Wheeze
o Weight loss
10
Q
Investigations for suspected COPD
A
• Lung function tests – reduced FEV1/FVC, reduced
PEFR, raised TLC, obstructive pattern
• FBC – PCV increased
• CXR – hyperinflation, flat hemidiaphragms, large
central pulmonary arteries
• ECG – RA and RV hypertrophy
• ABG – PaO2 decreased ± hypercapnia
• CT – emphysema
11
Q
Differentials for COPD
A
Pneumonia, heart failure, pulmonary embolus, lung cancer, asthma
12
Q
Lifestyle management of COPD
A
Smoking cessation, regular physical activity encouraged
13
Q
1st line drug treament for COPD
A
SABA/SAMA
14
Q
2nd line drug treatment for COPD
A
LABA/LAMA
15
Q
3rd line drug treatment for COPD
A
LABA/LAMA + corticosteroid
16
Q
4th line drug treatment for COPD
A
LABA + LAMA + corticosteroid
17
Q
5th line drug treatment for COPD
A
Long term oxygen therapy -> sats of 88-92%
18
Q
Surgical management of COPD
A
Lung transplant if drugs insufficient
19
Q
What is asthma?
A
Reversible obstruction of the airways, bronchospasm and excessive airway secretions, usually a hypersensitivity type 1 reaction
20
Q
What is extrinsic asthma?
A
Asthma triggered by an allergen (dust, foods, animals, pollens) type 1 hypersensitivity, IgE mediated
21
Q
What type of hypersensitivity is occupational asthma?
A
Type 1
22
Q
What is intrinsic asthma?
A
Not immune-mediated, non-allergic, triggered by; cold, infection, stress, exercise, SO2, pollutants etc.
23
Q
What are the 3 factors that contribute to airways narrowing in asthma?
A
o Bronchial muscle contraction
o Mucosal swelling/inflammation
o Increased mucus production
24
Q
What causes mucosal swelling/inflammation in asthma?
A
Mast cell and basophil degranulation -> release of leukotrienes and prostaglandins
25
What are the two main phenotypes of asthma?
Eosinophillic and non-eosinophillic
26
Features of asthma
• Episodic cough, breathlessness
• Diurnal variation – worse at night
• Provoking factors – allergens, infections, menstrual
cycle, exercise, cold air, laughter/emotion
• Other atopic disease – eczema, hayfever
27
Signs of asthma
* Tachypnoea
* Audible wheeze
* Hyperinflated chest
28
Investigations for suspected asthma
* Spirometry – FEV1/FVC <70% + reversibility testing
* PEF- keep diary
* Sputum and blood culture, ABG, CXR
29
Differentials for asthma
Pulmonary oedema, COPD, tumour
30
Step 1 drug treament for asthma
SABA (salbutamol) PRN – max once daily
31
Step 2 drug treament for asthma
+ inhaled corticosteroid (beclomethasone) once daily
32
Step 3 drug treatment for asthma
+ leukotriene receptor antagonist (LTRA)
33
Step 4 drug treatment for asthma
+ LABA (salmeterol inhaler 12 hourly) ± LTRA
34
Step 5 drug treatment for asthma
+ oral prednisolone
35
Epidemiology of lung cancer
* M:F, 2:1
| * 1/3 of all cancer deaths
36
Causes of lung cancer
* Cigarettes
* Occupational – asbestos etc.
* Lung fibrosis
37
Signs and symptoms of lung cancer
* Cough
* Recurrent chest infections
* Haemoptysis
* Increasing SOB
* Extra-pulmonary changes
* Malaise
* Weight loss
38
Investigations for suspected lung cancer
o Sputum sample
o BAL
o Biopsy
o Lobectomy, wedge, pneumonectomy
39
What is the most common type of lung cancer?
Non-small cell lung carcinoma
40
What is the main treatment for small cell lung carcinoma?
Chemotherapy
41
At what stage does lung cancer usually present?
Late stage, metastases
42
What are the main treatments used for non-small cell lung carcinoma?
Radiotherapy and surgery
43
Symptoms of pulmonary embolism
Breathlessness, pleuritic chest pain, DVT signs/symptoms, RF’s
44
Risk factors for pulmonary embolism
* Surgery, immobility
* OC pill, HRT, Pregnancy
* Long haul flights/ travel (rare)
* Inherited thrombophilia - genetic predisposition
45
Signs of pulmonary embolism
Tachycardia, tachypnoea, pleural rub, none of alternative diagnosis
46
Investigations for suspected pulmonary embolism
```
o CXR usually normal
o ECG – sinus tachycardia
o Blood gases – type 1 respiratory failure
o D-dimer
o CTPA spiral CT with contrast
```
47
Management of PE
* LMW Heparin for min 5 days
| * Oral warfarin (INR 2-3) for 6 months
48
Prevention of PE
Compression stockings, hydration and early mobilisation
49
Causes of adult respiratory distress syndrome (ARDS)
Shock, trauma, infections, gas inhalation (NO2 etc.), narcotic abuse
50
Pathology of ARDS
Lung damage and release of inflammatory mediators -> increased capillary permeability -> non-cardiogenic pulmonary oedema, alveolar infiltrate + hyaline membranes -> multiorgan failure
51
Signs and symptoms of ARDS
Acute onset, SOB, tachypnoea, tachycardia, peripheral vasodilation, bilateral inspiratory crackles, hypoxaemia -> cyanosis
52
Investigations for suspected ARDS
o Bloods – FBC, U&E, LFT, CRP, cultures, ABG
o CXR – bilateral pulmonary infiltrates
o Pulmonary artery catheter – measure pulmonary capillary wedge pressure <19mmHg
53
Management of ARDS
Admit to ITU, supportive therapy, treat underlying cause
54
What is fibrosing alveolitis (Idiopathic Pulmonary Fibrosis)?
Fibrosis of lung interstitium causing restrictive respiratory defect, cause unknown
55
Symptoms of pulmonary fibrosis
Breathlessness, respiratory failure -> cor pulmonae
56
Signs of pulmonary fibrosis
Finger clubbing, inspiratory basal crackles
57
Investigations for suspected pulmonary fibrosis
o CXR – ground glass -> honeycomb lung
o HRCT – most sensitive
o ABG – hypoxia
o Spirometry – FEV1/FVC ratio normal, FVC low
58
Management of pulmonary fibrosis
o Prednisolone
| o Lung transplant
59
What is sarcoidosis?
Autoimmune granulomatous disease, wide-spread but mainly affecting the lungs
60
Epidemiology of sarcodosis
young Afro-American women
61
Cause of sarcoidosis
Mostly unknown, genetic link, autoimmune
62
Signs and symptoms of sarcoidosis
o General – fever, weight loss, fatigue
o Pulmonary – dry cough, dyspnoea
o Other – lymphadenopathy, hepatosplenomegaly,
conjunctivitis, glaucoma, erythema nodosum etc.
63
Investigations for suspected sarcoidosis
o CXR – bilateral hilar lymphadenopathy
o Bloods – high ESR, high ACE, high calcium
o Lung function tests – normal or restrictive
o Tissue biopsy – diagnostic
o Kveim test
64
Management of sarcoidosis
o Minimal symptoms – resolve spontaneously within
few weeks, remission in few years
o Severe symptoms – prednisolone
o Lung transplantation
65
What is bronchiectasis?
Permanent dilatation of bronchi and bronchioles due to obstruction or severe inflammation
66
Pathophysiology of bronchiectasis
* Chronic inflammation of airways -> irreversible damage -> bronchioles scarred + dilated, cilia lost
* Permanent dilatation impairs muco-ciliary clearance -> mucus builds up
67
Causes of bronchiectasis
* Post-infection – H. influenzae, Strep. Pneumoniae
* Congenital – CF, primary ciliary dyskinesia
* Bronchial obstruction
68
Symptoms of bronchiectasis
* Persistent cough with foul-smelling sputum
* Haemoptysis
* Dyspnoea
69
Signs of bronchiectasis
* Finger clubbing
* Inspiratory crepitations
* Wheeze
70
Investigations for suspected bronchiectasis
* Sputum culture
* CXR/CT – cystic shadows, thickened bronchial walls
* Spirometry – obstructive pattern
* Bronchoscopy
71
Management of bronchiectasis
* Airway clearance techniques and mucolytics
* Antibiotics
* Bronchodilators if asthma, COPD, CF
* Corticosteroids if ABPA
72
Cause of cystic fibrosis
Autosomal recessive inheritance – mutations in the CFTR gene on chromosome 7
73
Epidemiology of cystic fibrosis
More common in Causcasians
74
Pathology of cystic fibrosis
Mutated CFTR gene -> misfolded protein can’t migrate from endoplasmic reticulum to cell membrane -> lack of CFTR protein on epithelial surface -> can’t pump chloride ions out -> water not drawn in -> thick secretions
75
CF signs and symptoms in a newborn
Meconium ileus, failure to thrive
76
Signs and symptoms of CF in children and young adults
o Pancreatic – blocked pancreatic ducts:
- protein and fat malabsorption -> failure to gain
weight and thrive
- frequent pancreatitis -> fibrosis
- DM
o Respiratory:
- thick mucus -> defective mucociliary action ->
infection -> CF exacerbation (cough and fever, CXR
changes)
- bronchiectasis
- repeated exacerbations -> respiratory failure
o Other:
- infertility in males – lack vas deferens
- digital clubbing
- nasal polyps
77
Investigations for cystic fibrosis
* Newborn screening – detects IRT, present in CF
* Sweat test – high Cl- >60mmol/L
* Genetic testing
78
Management of cystic fibrosis
```
• Fat soluble vitamins (ADEK), replacement pancreatic enzymes
• Pulmonary treatment:
o Chest physiotherapy
o Inhalers (bronchodilators)
o Mucolytics – Dornase alfa
o Lung function tests + annual CXR
o Lung transplant
```
79
What is a pneumothorax?
Air in the pleural space between the lungs and chest wall, causing collapse of the lung
80
Causes of pneumothorax
* Often spontaneous (young, thin men)
* Chronic lung disease – asthma, COPD, CF
* Infection – TB pneumonia
* Trauma
* Carcinoma
* Connective tissue disorders – Ehlers-Danlos
81
Symptoms of pneumothorax
* May be asymptomatic
| * Sudden onset dyspnoea ± pleuritic chest pain
82
Signs of pneumothroax
* Reduced expansion
* Hyper-resonance to percussion
* Diminished breath sounds
* Tracheal deviation if tension pneumothorax
83
Investigations for suspected pneumothorax
* CXR – area devoid of lung markings
| * ABG
84
Management of pneumothorax
```
• Primary – SOB or >2cm on CXR -> aspiration ->
chest drain if unresolved
• Secondary:
o <1cm – observe 24hrs
o 1-2cm – aspirate
o >2cm/SOB – chest drain
```
85
What is a tension pneumothorax?
Tension pneumothorax – air drawn into pleural space with each inspiration has no route of escape during expiration
86
What is a pleural effusion?
A collection of excess fluid in the pleural space, can restrict lung expansion
87
Pathophysiology of transudative pleural effusion
Too much fluid leaves capillaries due to increased hydrostatic pressure or decreased oncotic pressure
88
Causes of transudative pleural effusion
Heart failure (-> PAH), cirrhosis, nephrotic syndrome
89
Pathophysiology of exudative plerual effusion
Inflammation of pulmonary capillaries -> leakier
90
Causes of exudative pleural effusion
Trauma, malignacy, lupus, infection
91
Symptoms of pleural effusion
* Pleurisy – pain on inhaling
| * Dysnoea
92
Signs of pleural effusion
* Decreased breath sounds
* Dullness to percussion
* Decreased tactile fremitus
93
Investigations for suspected pleural effusion
• CXR – decreased aeration, tracheal deviation,
blurred costophrenic angle
• Chest examination
• Thoracentesis – remove fluid and find out cause y
94
How is a thoracentesis analysed/interpreted?
Light criteria:
o Transudate – clear, <25g//L protein
o Exudate – cloudy, >35g/L
o Lymphatic/empyema – milky
95
Management of pleural effusion
* Drain if symptomatic
* Pleurodesis with talc if recurrent
* Surgery
96
What is pulmonary hypertension?
Chronic high blood pressure in pulmonary circulation, mean pulmonary arterial pressure >25mmHg
97
Causes of pulmonary hypertension
• Left heart disease – HF, valve dysfunction
• Chronic lung disease – emphysema
• PAH – congenital heart defects, connective tissue
disorders, infections
98
How does left heart disease lead to pulmonary hypertension?
Left side of heart unable to pump efficiently -> backup of blood in pulmonary circulation -> increased pressure in pulmonary arteries
99
How does chronic lung disease, such as emphysema, lead to pulmonary hypertension?
o Diseased area in lung -> unable to deliver oxygen to blood -> pulmonary arterioles constrict -> blood shuttled away from damaged areas
o If widespread -> overall increase in pulmonary vascular resistance -> right side of heart must generate increased pressure -> pulmonary hypertension
100
Signs and symptoms of pulmonary hypertension
• SOB – can be worse when lying flat
• Pulmonary oedema
• Right ventricular hypertrophy -> right heart failure ->
ankle swelling, hepatomegaly
101
Investigations for suspected pulmonary hypertension
• Echocardiogram – increased pressure in right-
ventricle and pulmonary arteries
• Spirometry – underlying lung disease
102
Management of pulmonary hypertension
* Supplemental oxygen
| * Treat underlying cause
103
What are the fours types of occupational lung disease? Give and example of each
o Inert: coal worker’s pneumoconiosis
o Fibrous: progressive massive fibrosis
o Allergic: extrinsic allergic alveolitis
o Neoplastic: mesothelioma, lung cancer
104
What cells are damaged by coal dust?
Alveolar macrophages
105
Presentation of coal workers pneumoconiosis
o Progressive massive fibrosis (PMF)
o Emphysema
o Honeycomb lung and/or cor pulmonale
106
Features of silicosis
* Tissue destruction and fibrosis
* Nodules are formed after many years of exposure
* Interstitial fibrosis
* Raised incidence of TB
107
What lung conditions can asbestos cause?
Diffuse pulmonary fibrosis (asbestosis), diffuse pleural fibrosis, persistent pleural effusion, plaque, lung cancer, mesothelioma
108
Give 2 causes of extrinsic allergic alveolitis
Bird fancier’s lung (protein in bird droppings), Farmer’s lung (fungus from mouldy hay)
109
Pathophysiology of extrinsic allergic alveolitis
Type 3 hypersensitivity -> bronchiolitis -> chronic inflammation and granulomas -> resolve or lead to fibrosis
110
Signs and symptoms of extrinsic allergic alveolitis
Dry cough, dyspnoea, weight loss, finger clubbing, type 1 resp failure, cor pulmonale
111
Investigations for suspected extrinsic allergic alveolitis
o Bloods – ABG, antibodies, FBC, high ESR
o CXR – upper mottling/consolidation -> honeycomb
o CT – fibrosis, nodules
o Lung function tests – restrictive
112
Management of extrinsic allergic alveolitis
o Allergen avoidance, or face mask
| o Prednisolone
113
What is Goodpasture's syndrome?
An autoimmune disease characterised by kidney and lung symptoms
114
Risk factors for Goodpasture's syndrome
HLA-DR15 genes, infections, smoking, oxidative stress, hydrocarbon-based solvents
115
Pathophysiology of Goodpasture's syndrome
Autoantibodies attack collagen (most abundant in kidneys and lungs) – type II hypersensitivity
116
Signs and symptoms of Goodpasture's syndrome
• Respiratory (first) – haemoptysis, cough, restrictive
lung disease
• Kidneys – haematuria, proteinuria, nephritic
syndrome
117
Investigations for suspected Goodpasture's syndrome
* CXR – infiltrates due to pulmonary haemorrhage
| * Kidney biopsy – crescentic glomerulonephritis
118
Management of Goodpasture's syndrome
Vigorous immunosuppressive treatment and plasmapheresis
119
What is mesothelioma?
A tumour of mesothelial cells that usually occurs in the pleura, rarely in peritoneum
120
What is the main cause of mesothelioma?
Asbestos exposure
121
Signs and symptoms of mesothelioma
* Chest pain
* Dyspnoea
* Weight loss
* Digital clubbing
* Recurrent pleural effusions
122
Investigations for suspected mesothelioma
* CXR/CT – pleural thickening/effusion
* Pleural fluid – bloody
* Thoroscopy – histology diagnostic (post-mortem)
123
Management of mesothelioma
* Chemotherapy
* Surgery and radiotherapy controversial
* Pleural drainage
* Incurable
124
Risk factors for TB
Born in high prevalence area, IVDU, homeless, alcoholic, prisons, HIV+
125
How us TB usually spread?
Aerosol
126
What culture plate is used to culture mycobacterium tuberculosis?
Lowenstein-Jensen culture pate
127
What stain is used to detect acid-fast mycobacterium?
Ziehl-Neelson stain
128
Pathology of TB
o >95% have no disease – immune system kills
majority of infecting bacilli
o 2-5% develop primary pulmonary disease:
- Bacilli taken into lymphatics to hilar lymph nodes ->
enlarge
- Bacilli + macrophages form granuloma -> grows into
cavity in apex of lung -> cavity full of TB bacilli,
expelled when patient coughs
129
Why do granulomas usually form in the apex of the lung?
More air/less blood and immune cells
130
Signs and symptoms of TB
o Systemic - Weight loss, low grade fever, anorexia,
night sweats, malaise
o Pulmonary TB - cough >3 weeks, chest pain,
breathlessness, haemoptysis
131
Investigations for suspected TB
o CXR – fibronodular/linear opacities
o 3x sputum - gold standard
o Urine, CSF, pleural fluid, biopsy specimen
132
What test can be used to detect latent TB?
Tuberculin skin test ‘Mantoux’, Interferon-gamma release assays (IGRAS)
133
What are the four drugs used to treat TB?
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
134
Give a side effect of rifampicin
Orange urine/tears/sweat
135
Give 2 side effects of isoniazid
Neuropathy, hepatitis
136
Give 2 side effects of pyrazinamide
Arthralgia, hepatitis
137
Give a side effect of ethambutol
Eyes - optic neuritis
138
What causes seasonal flu epidemics?
Antigenic drift, usually influenza A
139
What causes a flu pandemic?
Antigenic shift
140
How is influenza spread?
Aerosol (coughs and sneezes), hand-to-hand contact
141
What is the incubation period for influenza?
1-3 days
142
Symptoms of influenza
Upper and/or lower respiratory tract symptoms, fever, headache, myalgia and weakness
143
Management of influenza
o Supportive care – oxygenation, hydration/nutrition,
prevent/treat secondary infections, paracetamol
o Tamiflu if high risk
o Prevention – annual vaccine in UK
144
Give 4 common pathogens that cause pneumonia
Strep. Pneumoniae, Haemophilus Influenza, Staph Aureus, Klebsiella Pneumoniae
145
Give 2 pathogens that cause hospital acquired pneumonia
Chlamydia, Legionella
146
Pathology of pneumonia
Bacteria colonise in lungs -> inflammation
147
Symptoms of pneumonia
o Fever, sweats, rigors
o Cough, SOB, sputum
o Pleuritic chest pain (pain worse on deep breathing)
o Weakness, malaise
148
What does rusty coloured sputum suggest?
Strep. pneumoniae infection
149
Signs of pneumonia
o Raised respiratory and heart rates, low BP, fever,
dehydration
o Dull to percussion (consolidation), bronchial breath
sounds, crackles ± wheeze
150
Investigations for suspected pneumonia
o Chest X-ray – consolidation
o Bloods – FBC, WCC, U&E, LFTs, CRP
o Sputum, blood cultures
o Urinary antigen test (Legionella’s = ELISA)
151
How is pneumonia severity assessed?
```
CURB65 – 3+ hospitalise, 2 short stay and monitor closely:
o Confusion
o Urea (>7)
o Respiratory rate (>30)
o Blood pressure (>90/60)
o >65
```
152
What antibiotics would you give to treat a H. Influenzae infection?
Amoxicillin
153
What antibiotics would you give to treat a Stap, Aureus infection?
Flucloxacillin
154
What antibiotics would you give to treat a Klebsiella Pneumoniae infection?
CO-amoxiclav
155
What antibiotics would you give to treat a Legionella infection?
Clarithromycin
156
What is the criteria used to determine the likelihood of a sore throat having a bacterial cause?
```
Centor Criteria:
o Tonsillar exudate
o Tender anterior cervical adenopathy
o Fever >38⁰C
o No cough
```
157
Give 3 common causes of bronchitis
Viral - adenovirus, rhinovirus, parainfluenzae
158
Clinical features of bronchitis
o Cough, productive or non-productive, > 5 days
| o SOB +/- wheeze, no signs of focal consolidation
159
Causes of pharyngitis
Viral - adenovirus, rhinovirus
| Bacterial - Strep. pyogenes
160
What antibiotics would you give for a Strep. Pyogenes infection?
Amoxicillin
161
Causes of sinusitis
o Usually viral – rhinovirus
| o Less bacterial – strep. pneumoniae, H influenzae
162
Cause of epiglottitis
Haemophilus influenzae type B (HIB)
163
Presentation of epiglottitis
• Children 2-4 years old with fever, dysphagia,
drooling and stridor
• Thumb sign on XR
164
What organism causes whooping cough
Bordetella pertussis
165
What antibiotics would you give for a Bordetella pertussis infection?
Clarithromycin
166
What is the incubation period of Bordetella pertussis?
7-10 days
167
What are the 4 clinical features of whooping cough?
o Coughing spasms
o Inspiratory ‘whoop’
o Post-ptussive vomiting
o Cough >14 days
168
Cause of Croup
Parainfluenza virus
169
What blood test would you do to test for Goodpastures?
Anti-GBM
170
What is the most common type of non-small cell carcinoma?
Adenocarcinoma
171
Give 2 features of pulmonary hypertension on x-ray
o Enlargemeed pulmonary arteries
| o Enlarged right atrium,
