Resp Flashcards
Name four features of moderate acute asthma
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
Name four features of severe acute asthma
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
Name five features of life threatening acute asthma
PEFR < 33% best or predicted Oxygen sats < 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma
Normal CO2 in acute asthma attack indicates what?
Exhaustion
Classify as life threatening
What are the three most common causes of acute exacerbation of COPD?
Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis
What is management of acute exacerbation of COPD?
- Increase frequency of bronchodilator
- 7-14 days of 30mg Prednisolone
- Antibiotics if signs of pneumonia (Amoxicillin or Tetracycline or Clarithromycin)
What are the pathogenesis and features of acute respiratory distress syndrome (ARDS)?
Increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli.
Criteria:
- Acute onset (<1 weeks of known risk factor)
- Pulmonary oedema (bilateral infiltrates on CXR)
- Non-cardiogenic
- p)2/FiO2 <40kPa
Treatment: Aim for FiO2 below 40%. Add PEEP might help. Maintain low tidal volume ventilation.
What are the features and investigation findings of allergic bronchopulmonary aspergillosis?
Due to allergy to aspergillus spores. History of bronchiectasis and eosinophilia
Features
bronchoconstriction: wheeze, cough, dyspnoea. ?asthmatic
bronchiectasis (proximal)
Investigations
eosinophilia
flitting CXR changes
positive radioallergosorbent (RAST) test to Aspergillus
positive IgG precipitins (not as positive as in aspergilloma)
raised IgE
Management of allergic bronchopulmonary aspergillosis?
Steroids
Itraconazole as second line
Features of alpha-1 antitrypsin deficiency?
Panacinar emphysema
Liver cirrhosis and HCC
Management of alpha-1 antitrypsin deficiency?
no smoking
supportive: bronchodilators, physiotherapy
intravenous alpha1-antitrypsin protein concentrates
surgery: lung volume reduction surgery, lung transplantation
Management of HACE and HAPE (altitude)?
Management of HACE
descent
dexamethasone
Management of HAPE
descent
nifedipine, dexamethasone, acetazolamide, phosphodiesterase type V inhibitors*
oxygen if available
Latent period of asbestos exposure for:
Pleural plaques
Asbestosis
Pleural plaques 20-40 years
Asbestosis 15-30 years
What bacteria are often implicated in aspiration?
The bacteria often implicated in aspiration pneumonia are aerobic, and often include: Streptococcus pneumoniae Staphylococcus aureus Haemophilus influenzae Pseudomonas aeruginosa
Other aerobic, and anaerobic, organisms can also result in aspiration pneumonia, but are less common.
Management of acute asthma attack?
- Nebuliser Salbutamol and Ipratropium Bromide
- Magnesium Sulphate (1.2-2g IV over 20 mins)
- If no response, consider IV salbutamol
Diagnosis of asthma?
Age > 17 (all below)
- Symptoms better/worse away from work. If so, refer for occupational asthma
- Spirometry with bronchodilator reversibility test
- FeNO test
Age 5-16
- Spirometry with bronchodilator reversibility test
- FeNO test if normal spirometry or obstructive spirometry with negative BDR test
NOTE:
FeNO >40 positive
Spiro FEV1/FVC ratio <70% is obstructive
Reversibility Improvement FEV1 12% or more and increase in volume of 200ml or more
What seven things are associated with occupational asthma? How can you investigate?
isocyanates - the most common cause. Example occupations include spray painting and foam moulding using adhesives platinum salts soldering flux resin glutaraldehyde flour epoxy resins proteolytic enzymes
Serial measurements of peak expiratory flow are recommended at work and away from work.
What is Berylliosis?
Name two features and two occupational risk factors
Occupational lung disease caused by inhalation of fumes of molten beryllium.
Features: Lung fibtosis and bilateral hilar lymphadenopathy
Occupational risk factors:
Aerospace industry
Manufacture of fluorescent light bulbs/golf club heads
Name four contraindications to chest drain
INR >1.3
Platelet Count <75
Pulmonary Bullae
Pleural Adhesions
Name five complications of chest drain insertion
Failure of insertion Bleeding Infection Penetration of lung Re-expansion pulmonary oedema
Should not exceed 1L fluid over 6 hours or may cause re-expansion pulmonary oedema
When should chest drain be removed for fluid draining or pneumothorax?
Fluid: When no output for > 24 hours and resolution of collection on imaging
Pneumothorax: When no longer bubbling spontaneously/when coughs and imaging shows resolution
Name 7 causes of bronchiectasis
post-infective: tuberculosis, measles, pertussis, pneumonia
cystic fibrosis
bronchial obstruction e.g. lung cancer/foreign body
immune deficiency: selective IgA, hypogammaglobulinaemia
allergic bronchopulmonary aspergillosis (ABPA)
ciliary dyskinetic syndromes: Kartagener’s syndrome, Young’s syndrome
yellow nail syndrome
Most common organisms isolated from bronchiectasis patients?
Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
Management of bronchiectasis?
Physical training Postural drainage Antibiotics for exacerbations Long term rotating antibiotics Bronchodilators for some Immunisations
What is bronchiolitis? Name five features
Acute bronchiolar inflammation
75-80% caused by RSV
coryzal symptoms (including mild fever) precede:
dry cough
increasing breathlessness
wheezing, fine inspiratory crackles (not always present)
feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission
Differentials for cavitating lung lesion on CXR? (name 7)
abscess (Staph aureus, Klebsiella and Pseudomonas)
squamous cell lung cancer
tuberculosis
Wegener’s granulomatosis
pulmonary embolism
rheumatoid arthritis
aspergillosis, histoplasmosis, coccidioidomycosis
Differentials for coin lesions on CXR? Name 4
malignant tumour: lung cancer or metastases
benign tumour: hamartoma
infection: pneumonia, abscess, TB, hydatid cyst
AV malformation
Causes of lobar collapse on X-Ray? Name 3
lung cancer (the most common cause in older adults)
asthma (due to mucous plugging)
foreign body
Name five cancers that commonly metastases to lung?
Which causes cannonball metastases?
breast cancer colorectal cancer renal cell cancer bladder cancer prostate cancer
Cannonball metastases commonly renal
Causes of lung white out as by trachea deviation (pulled towards, central, pushed away)
Pulled Toward:
Pneumonectomy
Complete lung collapse
Pulmonary Hypoplasia
Central:
Consolidation
Pulmonary oedema
Mesothelioma
Pushed Away:
Pleural effusion
Diaphragmatic hernia
Large thoracic mass
Name five causes of COPD
Smoking!
Alpha-1 antitrypsin deficiency
Other causes cadmium (used in smelting) coal cotton cement grain
How is COPD diagnosed and then categorised?
Post-bronchodilator FEV1/FVC <0.7
Mild >80% FEV1
Moderate 50-79%
Severe 30-49%
Very Severe <30%
Investigations for COPD?
Post bronchodilator spirometry
CXR
FBC
BMI
Who qualifies for LTOT in COPD? Who to assess and how?
What is the minimum time it must be used per day?
Assess if FEV1<30%, cyanosis, polycythaemia, perioheral oedema, raised JVP, O2 <92%
Assess with ABG 2x at least 3 weeks apart
Offer if pO2 <7.3kPa Offer if pO2 7.3-8kPa and secondary polycythaemia peripheral oedema pulmonary HTN
Do not offer if continue to smoke
15 hours per day (including night time)
What are the 7 steps of asthma management?
- SABA
- SABA + ICS (low)
- SABA + ICS (low) + LRTA
- Continue LRTA if effective. SABA + ICS (low) + LABA
- SABA +/- LRTA + MART (low)
- SABA +/- LRTA + MART (medium)
- SABA +/- LRTA + high dose ICS + LABA
Steroid
Low dose <400
Moderate 400-800
High >800
What are the steps for COPD stable management?
General: Smoking cessation Annual influenza vaccination One off pneumococcal vaccination Pulmonary rehab if functionally disabled
Medical:
1. SABA or SAMA
Not steroid responsive:
2. LABA + LAMA (+ SABA)
If steroid responsive (previous asthma/atopy, high eosinophils, substantial variation in FEV1 (>400ml), substantial diurnal variation in peak flow (at least 20%))
- LABA + ICS (+SABA/SAMA)
- LAMA + LABA + ICS + SABA
Oral theophylline - only after trials of short and long-acting bronchodilators. Reduce if macrolide co-prescribed
Prophylactic antibiotics:
Azithromycin (if optimal medical therapy and continue to have exacerbation)
Mucolytics: If chronic productive cough
Cor Pulmonale:
Loop diuretic +/- LTOT
Management of cystic fibrosis?
- BD Chest Physio and postural drainage
- High calorie diet
- Avoid contact with other CF
- Vitamin supplementation
- Pancreatic enzyme supplements
- Lumacaftor/Ivacaftor (Orkambi) - if homozygous for dF508 mutation
Features of eGPA
Churg Strauss
Small-medium vessel vasculitis
asthma blood eosinophilia (e.g. > 10%) paranasal sinusitis mononeuritis multiplex pANCA positive in 60%
eGPA associated with Leukotriene Receptor antagonists
Three Phases:
1. Atopy (asthma, rhinitis, sinusitis), 2. Eosinophilia >10% (pulmonary infiltrates), 3. Necrotizing multi-system small vessel vasculitis (rash, peripheral neuropathy, renal involvement - RPGN)
Features of extrinsic allergic alveolitis (aka Hypersensitivity Pneumonitis)
immune-complex mediated tissue damage (type III hypersensitivity) although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase.
Bird fanciers lung (avian protein)
Farmers lung (spores of Saccharopolyspora rectivirgula)
Malt workers lung (aspergillus clavatus)
Mushroom workers lung (terhmophilic actinomycetes)
Presentation
acute: occur 4-8 hrs after exposure, SOB, dry cough, fever
chronic
Patients well between episodes
Investigation
chest x-ray: upper/mid-zone fibrosis
bronchoalveolar lavage: lymphocytosis - eosinophilia
blood: NO eosinophilia
Acute neutrophilic inflammation followed by lymphocytic infiltration and colllagen deposition
Features of GPA?
Wegner’s Granulomatosis
Features
upper respiratory tract: epistaxis, sinusitis, nasal crusting
lower respiratory tract: dyspnoea, haemoptysis, cavitating lung lesions
rapidly progressive glomerulonephritis (‘pauci-immune’, 80% of patients)
saddle-shape nose deformity
also: vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesions
Investigations
cANCA positive in > 90%, pANCA positive in 25%
chest x-ray: wide variety of presentations, including cavitating lesions
renal biopsy: epithelial crescents in Bowman’s capsule
Management of GPA
steroids (methylprednisolone)
cyclophosphamide (90% response)
plasma exchange
median survival = 8-9 years
Features, investigation and management of idiopathic pulmonary fibrosis? What is life expectancy?
Features progressive exertional dyspnoea bibasal fine end-inspiratory crepitations on auscultation dry cough clubbing
Diagnosis: Spirometry - restrictive TCLO reduced Bilateral interstitial shadowing (ground glass --> honeycombing) ANA positive 30% RF positive 10% CXR - reticulonodular shadowing
Management:
Pulmonary rehabilitation
Pirfenidone
Supplemental O2
Life expectancy 4 years
Features of klebsiella pneumonia? Four things
more common in alcoholic and diabetics
may occur following aspiration
‘red-currant jelly’ sputum
often affects upper lobe
What is Lofgren’s Syndrome? What four features should I be aware of?
acute form sarcoidosis bilateral hilar lymphadenopathy (BHL) erythema nodosum, fever polyarthralgia.
More common in scandanavians
Good prognisis
Paraneoplastic syndromes from small cell lung cancer (3)
ADH
ACTH
Lambert-Eaton Syndrome
N.B. Usually centally located
Paraneoplastic syndromes from squamous cell lung cancer (3)
PTH-rp
Hypertrophic pulmonary osteoarthropathy
Ectopic TSH
NOTE: Also clubbing present
Paraneoplastic syndromes from adenocarcinoma lung cancer (1)
Hypertrophic pulmonary osteoarhropathy
NOTE: Gynaecomastia also present
For which lung cancer is PET scanning considered?
Non-small cell lung cancer
To establish eligibility for curative treatment
What is the management of Non-small cell lung cancer?
- Lobectomy if Stage 1, 2. Curative intent
NOTE: Perform mediastinoscopy prior to surgery for ?mediastinal lymph nodes - Radiotherapy if Stage 1, 2, 3. Curative intent
- Chemotherapy if Stage 3, 4. Improve survival and QoL
N.B.
Adjuvant chemotherapy if complete resection
Adjuvant radiotherapy if incomplete resection
Consider chemoradiotherapy for all stage 1-3 if not suitable for surgery
What is the management of small cell lung cancer?
- Surgery ONLY if very early Stage 1 or 2
Limited Stage T1-4, N0-3, M0
Cisplatin combination chemotherapy
Adjuvant radiotherapy only if good response to chemo
Extensive Stage M1
Platinum based chemotherapy
Adjuvant radiotherapy only if good response to chemo at both primary and metastasis
Relapse after initial treatment
Further Chemo
Palliative radiotherapy
Contraindications for surgery in non-small cell lung cancer?
assess general health
stage IIIb or IV (i.e. metastases present)
FEV1 < 1.5 litres is considered a general cut-off point*
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction
- if FEV1 < 1.5 for lobectomy or < 2.0 for pneumonectomy then some authorities advocate further lung function tests as operations may still go ahead based on the results
Causes of upper zone lung fibrosis (7)
hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis)
coal worker’s pneumoconiosis/progressive massive fibrosis
silicosis
sarcoidosis
ankylosing spondylitis (rare)
histiocytosis
tuberculosis
CHARTS C - Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis
Causes of lower zone lung fibrosis (4)
idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis
How to investigate suspected mesothelioma?
CXR
Pleural CT
If effusion, MC&S, biochemistry, cytology
Local anaesthetic thorascopy if negative effusion sample
Pleural nodularity on CT –> Image guidd pleural biopsy
Features of microscopic polyangitis?
Renal impairment Fever Palpable Purpura Cough/ SOB/Haemoptysis Diffuse alveolar haemorrhage Mononeuritis Multiplex Lethargy/Myalgia/Weight Loss
NOTE: Spares the URT
pANCA (against MPO) - positive in 50-75%
cANCA (against PR3) - positive in 40%
Where is MERS from and what is it caused by?
Middle East respiratory syndrome (MERS) is caused by the betacoronavirus MERS-CoV.
Arabian Peninsula
2-14 day incubation period
Lymphocytopenia
Thrombocytopenia
Derranged LFTs
Indications for non-invasive ventilation? (4)
COPD respiratory acidosis pH 7.25-35
Type 2 resp failure due to chest wall deformity, neuromuscular disease or OSAS
Cardiogenic pulmonary oedema unresponsive to CPAP
Weaning from tracheal intubation
Three main disease types for non-tuberculous mycobacteria?
Hypersensitivity like disease
Cavitating disease
Bronchiectasis with or without nodules
Features and management of obesity hypoventilation syndrome?
Morning headaches Daytime sleepiness Reduced exercise tolerance Poor concentration Day time hypercapnia
Management:
Weight loss
Assisted ventilation
Supplemental oxygen
Assessment and diagnostic tests for OSAS
Epworth Sleepiness Scale
Multiple Sleep Latency Test (how long to fall asleep in dark room)
Diagnostic Test: Sleep studies (polysomnography)
NOTE: Over long periods of time: CO2 compensated by renal retention of bicarbonate. Become CO2 retainers.
Management of OSAS?
Weight loss
CPAP
Intra-oral device if CPAP not tolerated OR mild OSAS with no daytime sleepiness
Should inform DVLA if excessive day time sleepiness
Causes of pleural transudate? What is the protein level?
(< 30g/L protein)
heart failure (most common transudate cause)
hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
hypothyroidism
Meigs’ syndrome
Causes of pleural exudate? What is the protein level?
(> 30g/L protein) infection: pneumonia (most common exudate cause), TB, subphrenic abscess connective tissue disease: RA, SLE neoplasia: lung cancer, mesothelioma, metastases pancreatitis pulmonary embolism Dressler's syndrome yellow nail syndrome
What is lights criteria and when is it used?
To distinguish between transudate and exudate if protein level 5-35g
Exudate if:
pleural fluid protein divided by serum protein >0.5
pleural fluid LDH divided by serum LDH >0.6
pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
What does low glucose in pleural fluid suggest?
rheumatoid arthritis, tuberculosis
What does raised amylase in pleural fluid suggest?
pancreatitis, oesophageal perforation
What does heavy blood staining in pleural fluid suggest?
mesothelioma, pulmonary embolism, tuberculosis
When would you suspect a pleural infection with a pleural effusion that requires chest drain insertion?
Fluid purulent or turbid
Clear fluid but pH <7.2 with suspected pleural infection
Features of mycoplasma pneumoniae?
Dry cough
Atypical CXR
AIHA
Erythema Multifrome
Features of legionella pneumophilia?
Hyponatraemia
Lymphopenia
Classically secondary to infected air conditioning
Components of CURB 65 score?
Confusion (AMTS 8 or less) Urea > 7 RR > 30 BP < 90 sys, <60 dys Age 65+
What to do with CURB 65 score of:
0
1
2
0 - manage community
1 - if sats >92%, manage in community and CXR. If bilateral/multilobar shadow, admit
2+ - admit
What are the risks associated with CURB 65 score?
0 -1 - Low risk <3% mortality
2+ - intermediate risk 3-15% mortality
3+ - high risk 15% mortality
When should you not discharge following a pneumonia?
If two or more in the past 24 hours
Temp 37.5 + RR 24 + HR 100+ BP <90 O2<90 Abnormal mental state Can't eat
Management of pneumothorax in Primary cases
<2cm and no SOB - consider discharge
Otherwise aspirate
If fails (remains >2cm or SOB), chest drain
Management of secondary pneumothorax?
If 50+ and >2cm and/or patient SOB - chest drain
Otherwise, if 1-2cm - aspirate. If fails (remains >1cm) - chest drain
If <1cm, give O2 and admit for 24 hours
(NOTE: 2cm = 50% pneumothorax)
Causes of pulmonary eosinophilia? (8)
Churg-Strauss syndrome allergic bronchopulmonary aspergillosis (ABPA) Loffler's syndrome eosinophilic pneumonia hypereosinophilic syndrome tropical pulmonary eosinophilia drugs: nitrofurantoin, sulphonamides, ampicillin, NSAIDs, minocycline less common: Wegener's granulomatosis
Cause of tropical pulmonary eosinophilia?
Wuchereria bancrofti/Brugia malayi infection
History of paroxysmal nocturnal cough
Wheeze
SOB
Diagnosis aided by clinical response to Diethylcarbamazine
Spread by mosquito
Mature in the lymphatics
Can cause elephantiasis
What is Loffler’s syndrome? Can you name some features?
Transient CXR shadow
Blood eosinophilia
Ascaris lumbricoides/strongyloides/ancylostoma causing an alveolar reaction
Fever, cough, night sweats
Self limiting (2 week)
Can treat with Mebendazole for 3 days
Can you classify the five types of pulmonary hypertension?
Pulmonary arterial hypertension - idiopathic
(familial, collagen disorder, cogenital heart disease with systemic shunts, drugs and toxins, persistent pulmonary HTN of newborn)
Pulmonary hypertension with left heart disease
(LV systolic and diastolic dysfunction, mitral stenosis, mitral regurgitation)
Pulmonary HTN secondary to lung disease/hypoxia
(COPD, ILD, OSAS, altitude)
Pulmonary HTN due to thromboembolic disease
Miscellaneous conditions
(lymphangiomatosis)
What are the Centor criteria?
presence of tonsillar exudate
tender anterior cervical lymphadenopathy or lymphadenitis
history of fever
absence of cough
What are the respiratory manifestations of rheumatoid arthritis?
pulmonary fibrosis
pleural effusion
pulmonary nodules
bronchiolitis obliterans
complications of drug therapy e.g. methotrexate pneumonitis
pleurisy
Caplan’s syndrome - massive fibrotic nodules with occupational coal dust exposure
infection (possibly atypical) secondary to immunosuppression
Name three syndromes associated with Sarcoidosis
Lofgren’s syndrome - BHL, erythema nodosum, fever, polyarthralgia (good prognosis)
Mikulicz Syndrome - elnargement of parotid and lacrimal glands (sarcoid, TB or lymphoma)
Heerfordt’s Syndrome (uveoparotid fever) - parotid enlargement, fever, uveitis
Features associated with sarcoidosis?
Acute: Erythema nodosum BHL Swinging fever Polyarthralgia
Insidious: SOB Non-productive cough Malaise Weight Loss
Skin:
Lupus pernio
Hypercalcaemia
Features of sarcoidosis and staging on chest x-ray?
stage 0 = normal
stage 1 = bilateral hilar lymphadenopathy (BHL)
stage 2 = BHL + interstitial infiltrates
stage 3 = diffuse interstitial infiltrates only
stage 4 = diffuse fibrosis
Sarcoidosis spirometry and tissue biopsy results?
Use of ACE levels?
spirometry: may show a restrictive defect
tissue biopsy: non-caseating granulomas
ACE levels have a sensitivity of 60% and specificity of 70% and are therefore not reliable in the diagnosis of sarcoidosis although they may have a role in monitoring disease activity.
Management of sarcoidosis?
Steroids if:
CXR - stage 2 or 3 with symptoms
Hypercalcaemia
Eye, heart or neuro involvement
Occupations at risk of silicosis? Features?
Mining
Slate works
Foundries
Potteries
Features:
Fibrosing lung disease
Egg shell calcification of hilar lymph nodes
Whos the coolest F2 I know? / Whos Milkshake Brings all the boys to the yard? / Who will bring balance to the force?
Dr Olli Sharp BMBS BSc
What is the air speed velocity of an unladen swallow
African or European?
What three options for smoking cessation are there?
Nicotine replacement therapy
Varenicline
Bupropion
Do not favour one over another. Do not combine
Prescribe for only 2 weeks after stop date for NRT, 3-4 weeks for the other two
If fail, do not represcribe within 6 months
Adverse effects of nicotine replacement therapy?
N&V
Headache
Flu like symptoms
Adverse effects of Varenicline?
Contraindication?
Start one week before stop date. 12 week course
Nausea
Headache
Insomnia
Abnormal dreans
Contraindication
Depression/self harm (relative)
Pregnancy
Breast feeding
Adverse effects of Varenicline?
Contraindication?
1-2 weeks before stop date
Contraindication Epilepsy Pregnancy Breast feeding Eating disorder (relative)
NOTE: Small risk of seizure
Smoking cessation in pregnant women?
All should be tested
- CBT, Motivational interview, structured self help
- Nicotine replacement therapy if fails
the other varenicline and bupropion are contraindicated
What are the guidelines for monitoring lung nodules?
< 5mm and benign - discharge
5-6mm or => 8mm and low risk - CT surveillance
=> 8mm and high risk - CT PET. If abnormal, biopsy
CT 5-6mm - at one year
CT =>6 - three months
Features and management of theophylline poisoning?
Features: Acidosis, Hypokalaemia Vomiting Tachycardia, arrhythmia Seizure
Management:
Gastric lavage
Activated charcoal
Seizures controlled by benzodiazepines or intubation
Causes of raised TLCO? (6)
asthma pulmonary haemorrhage (Wegener's, Goodpasture's) left-to-right cardiac shunts polycythaemia hyperkinetic states male gender, exercise
Causes of low TLCO? (7)
Restrictive lung disease • Idiopathic pulmonary fibrosis • Occupational lung disease • Hypersensitivity pneumonitis • Miliary tuberculosis • Pneumonectomy
Obstructive lung disease
• Cystic fibrosis
• Emphysema
Other causes
• Chronic pulmonary embolism
• Congestive heart failure (pulmonary oedema, low cardiac output)
• Primary pulmonary hypertension
Anaemia
Sites of secondary TB?
central nervous system (tuberculous meningitis - the most serious complication) vertebral bodies (Pott's disease) cervical lymph nodes (scrofuloderma) renal gastrointestinal tract
Management of latent TB? Two options…
NICE now give two choices for treating latent tuberculosis:
3 months of isoniazid (with pyridoxine) and rifampicin
6 months of isoniazid (with pyridoxine)
What is thunderstorm asthma?
Sudden spore and pollen release due to pressure change resulting in asthma attack
What levels of pressure should BiPAP be started on?
IPAP 15
EPAP 3
If pH <7.25 IPAP 20
Neuromuscular disease start with IPAP 10
Complications of NIV?
Breathing against machine (dyssynchrony)
Aspiration (vomiting/secretions) –> Mucous Plug
Pneumothorax
Ventilator associated pneumonia
In a patient with acute exacerbation of COPD with Type respiratory failure and acidosis, when should NIV be considered?
Failure of optimal medical therapy meaning hypercapnia and acidosis do not improve
The NIV
If fails to improve, for consideration of invasive ventilation
What can be used in COPD exacerbations when NIV is unavailable or inappropriate?
Respiratory Stimulants (doxapram)
Contraindications to NIV? (7)
Recent facial/upper airway surgery or injury
Recent UGI surgery
Confusion/agitation
Bowel obstruction
Upper airway obstruction
Excessive upper airway secreitions
Acute vomiting
Should nebulisers with NIV be given together or should the mask be taken off to administer nebuliser?
Take off mask to administer nebuliser
increased efficacy
Features and management of eosinophilic pneumonia?
Sub-acute respiratory symptoms
Alveolar/blood eosinophilia
Peripheral pulmonary infiltrates on imaging
Treat with oral corticosteroids
Good prognosis
When is Roflumilast used?
Already on maximal medical therapy
Recommended in COPD where =>2 exeracerbations per year and FEV1 <50%
Phosphodiesterase-4 inhibitor
Fun fact!
Silicosis increases susceptibility to TB
Most common cause of cannon ball metastases?
Renal cell cancer
Name two common scenarios in which CPAP is used?
OSAS
Pulmonary Oedema
What is Mepolizumab? When is it used?
IL-5 antagonist (monoclonal antibody)
Treatment of severe eosinophilia
resistant asthma
What is omalizumab? When is it used?
Treatment of allergic asthma with significant elevation in IgE
Add on therapy for step four.
What might you give for symptomatic relief of SOB in end stage COPD?
Opioids
+/- Benzodiazepines
Renal Failure: Alfentanil
What is the significance of nasal polyps in asthma?
More likely to have an adverse reaction to NSAIDs
What is the time lag for complications following asbestos exposure?
Is compensation possible?
10 Years - pleural plaque
20 Years - asbestosis
30 Years - Mesothelioma
NOTE: Clubbing is associated with progression to mesothelioma
Compensation for asbestosis or mesothelioma from Department of Social Security or Civil Law Claim
What is hypertrophic pulmonary osteoarthropathy and how does it present?
Intermittent aching and swelling in wrists and ankles (squamous cell lung cancer)
What are the investigation findings for invasive aspergillosis?
How is it treated?
Classical halo sign on CT
Hyphae on silver staining
Mortality 40-90%
- Voriconazole (IV)
- Lipsomal Amphotericin
What is re-expansion pulmonary oedema?
When does it occur?
Life threatening condition. Following chest drain insertion. Large volume or air is rapidly drained
Sudden onset SOB
Cough
Hypoxaemia
Where is histoplasma endemic?
What is the treatment?
What are the features?
Mississippi River Valley
Mild: Itraconazole
Severe: Admit, IV Amphotericin B
Signs: Fevers, mildly elevated WBC, nodular shadow on CXR, urine and serum antigen positive
May present many years down the line
What does raised Beta-D-glucan suggest?
Suggests fungal infection
Investigations in Pulmonary hypertension. What can you use?
RIght Heart Catheterisation - assess pulmonary pressures
Left Heart Catheterisation - assess coronary arteries
6 minute walk test - assess prognosis
SOB following TIPS. What possible complication has occurred?
Pulmonary Hypertension
- due to increased cardiac preload -
If during the LTOT assessment in COPD patient, the PaCO2 has risen >1kPa, what should you do?
May have clinically unstable disease
Further medical optimisation
Re-assess at 4 weeks
Differential for Bilateral hilar lymphadenopathy?
Sarcpodpsos TB Malignancy Cystic Fibrosis eGPA HIV EEA Phenytoin Pneumoconioses (berylliosis)
How should you investigate for TB in HIV patients with CD4 <200?
IFN-gamma
Mantoux
Both should be done. If positive, clinical assessment to exclude active TB.
What is non-tuberculous mycobacteria (NTM)? What are common managements?
Presentation:
Hypersensitivity disease
Cavitating disease
Bronchiectasis
Radiology: Cavities, bronchiectasis, nodules
Microbiology: 2 or more positive sputum samples on separate days
Mycobacterium Avium Complex (MAC) - Rifampicin, Clarithromycin, ethambutol (until sputum culture negative for 12 months)
M. Kansaii: Rifampicin, isoniazid, ethambutol (until sputum culture negative for 12 months)
What is the treatment of narcolepsy?
Methylphenidate
Nintedanib?Pirfenidone?
What are they used for?
Small molecule tyrosine kinase inhibitor inhibitor
Treatment of idiopathic pulmonary fibrosis
Use when:
FVC 50-80% predicted
Treatment is stopped if disease progression in any 12 month period
Name some drugs which can cause chronic cough?
ACEi Smoking Statins Amiodarone ARBs IFN-alpha IFN-beta
What is combined pulmonary fibrosis and emphysema (CPFE)?
Higher rates of lung cancer and risk of pulmonary arterial hypertension
Features: Exertional SOB Uppler Lobe Emphysema Lower lobe fibrosis Preserved lung volume Reduced capacity gas exchange
What is subglottic stenosis and how can it occur (3)?
Congenital
Idiopathic
Post-intubation
Consider if obstructive picture
What is chylothorax? What is it high in?
Accumulation of lymph in pleural space
High in triglycerides
and chylomicrons
What is a pseudochylothorax high in? When does it occur
Cholesterol
Occurs with longstanding fibrotic pleura
What drugs can cause pleural effusion?
Nitrofurantoin
MTX
Amiodarone
How should you investigate for TB? What is the best type?
Multiple samples (3 deep cough sputum samples) for microscopy and culture
If not possible, induction of sputum or bronchoscopy and lavage
Bronchoscopy - best specimen
Mantoux and IFN-gamma for latent TB
What does a high KCO but low DLCO imply for a patient with restrictive lung disease?
It is an extra-pulmonary cause
What is lymphangioleiomyomatosis?
Affects premenopausal women
Proliferation of smooth muscle cells in lungs, lymphatics and uterus
Likely caused by oestrogens
Association with Tuberous Sclerosis and renal angiomyolpomas
Symptoms:
SOB
Pneumothorax
Chylous pleural effusion
Management:
Medroxyprogesterone (anti-oestrogen)
What is atypical langerhans cell histiocytosis?
Affects smokers (age 20-40) SOB Cough Spontaneous Pneuomthorax Clubbing Granuloma infiltration in bones and hypothalamus
Symptoms and signs of Primary ciliary dyskinesia?
Autosomal recessive Sinusitis Otitis media Male infertility Recurrent respiratory infections 40-50% situs inversus
What is chronic eosinophilic pneumonia
SOB
Fever
Weight Loss
Skin, liver and spleen involvement
Atopic history - sinusitis, rhinitis, angioedema
Extensive dense peripheral infiltrates on CXR
What are the modified acute eosinophilic penumonia Philit Criteria?
- acute respiratory illness of less than or equal to 1-month duration
- pulmonary infiltrates on chest radiography or computed tomography (CT)
- pulmonary eosinophilia as demonstrated by more than 25% eosinophils in BAL fluid (can be accompanied by variably increased percentages of lymphocytes and neutrophils) or eosinophilic pneumonia on lung biopsy (bronchoscopic or surgical), and
- the absence of other specific pulmonary eosinophilic diseases e.g. eosinophilic granulomatosis with polyangiitis (previously known as Churg-Strauss syndrome)
What is the Kveim Test? What is it used for?
Part of spleen from patient with known sarcoidosis is injected under the skin
No longer used due to converns of cross infection
What is the bulging fissure sign and what is it seen in?
Classical feature of klebsiella pneumonia
Due to large volumes of consolidation (typically RUL) causing displacement of adjacent fissure
Rusty coloured sputum and proceeding herpes labialis?
Streptococcal pneumoniae
Proceeding flu like illness with subsequent rapid deterioration into a bacterial pneumonia?
Staphylococcus aureus
What is treatment for infected bronchiectasis?
Oral Ciprofloxacin 14 days
Failure of this: IV Tazocin, Ceftazidime, aztreonam, meropenem
Name two common pathogens in cystic fibrosis. Which has worse prognosis?
Pseudomonas Burkholderia (worse prognosis)
If draining a pneumothorax, at 3-5 days there is still an air leak/failure to re-expand, what should you do?
Thoracic surgical opinion
Which emphysema patients benefit from lung volume reduction surgery?
- UL emphysema and low exercise capacity (improved function and survival)
- UL and high exercise capacity (improved function, no difference survival)
- Non-UL and low exercise capacity
The following will not do well and have high risk of death:
- Non-UL and high exercise capacity
- Poor pulmonary function and homogenous emphysema distribution or poor CO diffusing capacity
Possible options for treatment to eradicate pseudomonas aeruginosa in CF patients?
IV anti-pseudomonal abx + inhaled aminoglycoside 14 days
Oral ciprofloxacin (6 weeks)
