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5thyr > Resp > Flashcards

Resp Flashcards

1
Q

What are the different divisions of a pleural effusion? (6)

A

Plural effusion is fluid within the plural space

  • Transudates - protein < 25g/L
  • Exudates - protein > 35g/L
  • Haemothorax = blood in pleural space
  • Chylothorax = lymph with fat in pleural space
  • Empyema = pus in the pleural space (pH < 7.2)
  • Haemopneumothorax = both blood and air in pleural space
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2
Q

What causes a transudative pleural effusion?

A 
TRANSUDATIVE EFFUSION 
-Increase in venous pressure causing increased hydrostatic pressure (FLUID shifts into pleural space)
-Causes:
   •Cardiac failure
   •Constrictive pericarditis

Hypoproteinaemia causing reduced oncotic pressure

  • Liver cirrhosis
  • Nephrotic syndrome
  • Malabsorption
  • CKD (abnormal leak of protein)

Others

  • Hypothyroidism
  • Meig’s syndrome - ascites, pleural effusion, BENIGN ovarian tumour
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3
Q

What causes an exudative effusion?

A

EXUDATIVE EFFUSION
-Caused by INFLAMMATION> causes PROTEIN to leak out of the tissues into the pleural space
-Causes of inflammation:
•Infection (TB/pneumonia)
•Malignancy (bronchial ca/lymphoma/mesothelioma) U/L!
•Inflammation (Rheumatoid arthritis/SLE/pancreatitis)
•Infarction (PE)

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4
Q

How does a pleural effusion present? (symptoms)

A

PLUERAL EFFUSION
Small pleural effusions (<300ml) are often asymptomatic

OR

  • Dyspnoea SOB
  • Pleuritic chest pain
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5
Q

What signs do you get in pleural effusion? (general exam/palpation/percussion/auscultation)

A

PLUERAL EFFUSION O/E
General
-May have signs of underlying disease (weight loss/clubbing/CLD stigmata/RA/hypothyroidism/butterfly rash

Palpation

  • Decreased expansion
  • Decreased tactile vocal fremitus
  • if MASSIVE- trachial deviation AWAY from effusion (> 1L)

Percussion
- Stony dull percussion note

Auscultation

  • Diminished breath sounds
  • Decreased vocal resonance
  • Bronchial breathing above the effusion where lung is compressed
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6
Q

What can be seen on a chest x-ray in pleural effusion?

A

PLEURAL EFFUSION

  • Blunting of costophrenic angles - 200ml of fluid required to be seen
  • Meniscus-shaped margin
  • Fluid in pleural fissure

Large effusion (>1L)

  • Complete opacification of the lung
  • Mediastinal/ tracheal shift AWAY from effusion
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7
Q

What is used to diagnose pleural effusion?

How do you do it?

A

Diagnotic thoracentesis/pleurocentesis

-Percuss upper border of pleural effusion and choose a site 1 or 2 intercostal spaces below it

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8
Q

What cytology results would indicate what in pleural fluid analysis? (neutrophils/lymphocytes/mesothelial cells, abnormal mesothelial cells/giant multinucleated cells)

A

Neutrophils ++

  • Pneumonia
  • PE

Lymphocytes ++

  • Malignancy
  • TB
  • RA, SLE, sarcoidosis

Mesothelial cells ++
- Pulmonary infarction

Abnormal mesothelial cells
-Mesothelioma

Giant multinucleated cells
- RA

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9
Q

What would raised amylase suggest in thoracentesis ?

A

Raised amylase in thoracentesis: pancreatitis or osophageal rupture (could also mean carcinoma or bacterial pneumonia)

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10
Q

What is calculated if the protein content of the effusion is equivocal (25-35g/L)? What levels are indicative of which type of pleural effusion?

A

Calculate Light’s Criteria (need to take bloods for serum glucose and total protein)

Transudative… (low protein, low LDH)
• Pleural fluid protein: serum protein ration < 0.5
• Pleural fluid LDH: serum LDH ratio < 0.6
• Pleural fluid LDH < 2/3 the upper limit of normal serum LDH

Exudative… (high protein, high LDH)
• Pleural fluid protein: serum protein ration > 0.5
• Pleural fluid LDH: serum LDH ratio > 0.6
• Pleural fluid LDH > 2/3 the upper limit of normal serum LDH

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11
Q

What is the management of pleural effusion?

A

Management of Plueral effusion

  • manage the underlying cause
  • Drainage (aspiration or chest drain)
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12
Q

What would you expect to see in an empyema? (Ph, LDH, glucose)

How do you treat an empyema?

A

Empyema

  • pH LOW
  • LDH high
  • glucose LOW (being used up by bacteria)

Treatment: chest drain under USS guidance and antibiotics

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13
Q

What investigation should you do fit pleural fluid analysis is inconclusive?

A

PLEUARL EFFUSION

-Do a percutaneous Pleural biopsy – if fluid analysis is inconclusive

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14
Q

What are complications of a chest drain?

A

Chest drain

  • can cause PULMONARY ODEMA - drain slowly (0.5-1.5L/24hrs)
  • never drain >1.5 litres
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15
Q

Treatment for recurrent pleural effusions?

A

Treatment for repeated pleural effusions
-Pleurodesis- stick visceral and parietal layers together

(with tetracycline, Bleomycin or sterile talc)

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16
Q

What causes pleural mesothelioma?

A

Asbestos exposure

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17
Q

What are the most common symptoms of pleural mesothelioma?

Investigation?

A 
Shortness of breath
Chest pain (non-pleuritic)

Thoracoscopy biopsy with stained biopsy - mesothelioma cells and psammoma bodies (looks like an onion)

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18
Q

In which patients does TB commonly occur? (4)

A
  • FOREIGN TRAVEL
  • HIV/immunocompromised
  • In those with an infective contact (always ask about infection in home contacts, this is most common cause for chilldren)
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19
Q

How do we manage contact preventing in cases of TB?

A

TB contact prevention

  • PHE should be informed
  • BCG should be offered to all high risk individuals at birth
  • DO NOT give BCG to HIV+ or other individuals at risk of immune compromise due to risk of dissemination
  • ALWAYS SCREEN FAMILY MEMBERS
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20
Q

After the initial inhalation of TB aerosol, what happens then? (2 options)

A

TB inhalation

  1. ~70% clear the infection
  2. ~30% get primary TB (classified by GOHNS focus)
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21
Q

People with primary TB, what happens then?

A

Primary TB
1. Effective T cell mediated response> latent TB
-cough subsides
-can get reactivated (most common cause of active TB)
-e.g. cancer or immunosuppressants
2. Non effective responce>Primary progressive TB
(linked with inadequate T cell immunity, e.g. HIV)

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22
Q

What are the possible symptoms of TB?

  • pulmonary
  • CNS
  • Cardiac
  • GU
  • Bones/joints
  • Skin
  • General
A 
TB symptoms 
-Pulmonary 
  •cough 
  •heamoptysis 
  •breathlessness (can cause atelectasis, bronchiectasis, pulmonary effusion)
  •chest pain (pleuritic)

-CNS
•headache
•altered mental state
•cranial nerve palsy

-Cardiac
•effusions/pericarditis

-Genito-urinary system 
   •Sterile pyuria 
   •Kidney pathologies 
   •Abscesses 
   •Salpingitis and infertiltiy 
   •Epididymo-orchitis

-Bones and joints
•back most common (Potts disease)

-Skin
•Lupus vulgarise (painful face nodule)

General: Lymphadenopathy, fever, weight loss, anorexia, fatigue, night sweats

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23
Q

What investigations would you do for TB?

A

ACTIVE TB INVESTIGATIONS
1. CXR is initial investigation (upper lobes affected)
2. Sputum Microscopy and culture
•3 early morning sputum samples
• Do a bronchial lavage sample via bronchoscopy if cant get sample (child)

Microscopy
-Ziehl-Neelsen stained looking for ACID FAST BACILLI

Culture
-Takes WEEKS (Lowenstein- Jensen media)

  1. Can also do PCR (see if resistant)
  2. Can also do biopsy and histology
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24
Q

What test screen people at HIGH RISK for TB (and contact tracing)?

What is a positive result, what does this mean?

Which people should you give the BCG vaccine?

A

Mantoux tuberculin skin test (latent TB)

  • Injection of antigen>type 4 hypersensitivity reaction
  • 5mm+ is a positive result if risk factors
  • 15mm+ is a positive result if no risk factors
  • This means they have either had a BCG before or had previous infection (latent TB)

If they have a negetive test, give the BCG vaccine

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25
Q

When would you get false negatives of mantoux test?

A

False negatives of mantoux test

  • weakened immune system (cant react)
  • really recent TB infection (within 10 weeks)
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26
Q

What TB test is NOT affected by previous infection?

What does a positive test mean?

A

Interferon-Gamma Release Assays (latent TB)

  • take blood, give blood antigen, look for IGR
  • Positive test indicates immune system has prior recognition of TB antigens (latent TB)
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27
Q

What area of the lung does TB normally affect?

A

TB affects upper lobe

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28
Q

What is milary TB?

What patients are most likely to get milary TB?

A

Milary TB

  • widespread disseminated TB by heamatogenous spread
  • 100% mortality if left untreated
  • appears as millet seeds when chest is re-infected via circulation
  • Immunocompromised patients
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29
Q

What is the treatment of ACTIVE TB?

A

ACTIVE TB treatment ‘RIPE’

  1. RIFAMPACIN
  2. ISONIAZID (and pyridoxine)
  3. PYRAZINAMIDE
  4. ETHAMBUTOL

TOTAL of 6 months
2 months of RIPE
4 months pf RI

*corticosteroids as adjunct

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30
Q

What is the treatment for LATENT TB?

A

LATENT TB (not always treated as 5-10% will get reactivation)
-6 months isoniazid
OR
-3 months of rifampicin + isoniazid

31
Q

What are the side effects of rifampicin?

A

RIFAMPICIN (crap GPs neumonic)
• P450 inducer (COCP, warfarin, statin inactivation)
• Liver toxicity (monitor LFTs)
• Orange urine

32
Q

What are the side effects of isoniazid?

A 
ISONIAZID (sick faces neumonic)
• Peripheral neuropathy - give pyridoxine to prevent this 
• P450 inhibitor 
• SLE-like symptoms 
• Liver toxicity (monitor LFTs)
33
Q

What are the side effects of pyrazinamide?

A

PYRAZINAMIDE
• may precipitate gout (hyperuriceamia)
• Liver toxicity (monitor LFTs)

34
Q

What is the main side effect to be aware of of ethambutol?

A

ETHAMBUTOL

•Optic neuritis - red/green colourblindness and peripheral vision STOP

35
Q

What would you see on LP of TB meningitis?

A

TB meningitis

fibrin, lymphocytes, ↓glucose, ↑protein

36
Q

What is the treatment of TB meningitis?

A

Treatment of meningitis TB
-2 months of RIPE (rifampicin, isoniazid, pyrazinamide, ethambutol)
-1 YEAR of RI
(plus Dexamethasone)

37
Q

What pathological features are there in pulmonary fibrosis?

A

Pulmonary fibrosis

  • Fibrosis and remodelling of the interstitium
  • Chronic inflammation
  • Hyperplasia of type II epithelial cells (the ones that secrete pulmonary surfactant to decrease surface tension within alveoli)
38
Q

What are some risk factors for developing pulmonary fibrosis?

A

Pulmonary fibrosis risk factors

  • Smoking
  • Occupation - silica, asbestos, heavy metals, mouldy foliage
  • Infection-chronic viral infections (hepatitis C, EBV)
  • GORD with micro-aspiration
  • Drugs e.g. methotrexate, nitrofurantoin, amiodarone, bleomycin
  • Rheumatological conditions e.g. sarcoidosis, ankylosing spondylitis, RA, scleroderma
39
Q

Symptoms of pulmonary fibrosis?

A

Pulmonary fibrosis (often affects patients >45 years)

  • Dry cough
  • Exertional dyspnoea (persistant and progressive)
  • Flu like symptoms (malaise, arthralgia)
  • Weight loss
40
Q

What signs would you see on examination of pulmonary fibrosis?

A

Pulmonary fibrosis signs

  • Cyanosis central or peripheral
  • Clubbing in 50%
  • BILATERAL FINE END INSPIRATORY CREPS
  • Decreased chest expansion
41
Q

What are the main complications of pulmonary fibrosis?

A

Pulmonary fibrosis complications

  • Respiratory failure
  • Increased risk of lung cancer

**3-4 year life expectancy

42
Q

What are the diagnostic tests for pulmonary fibrosis?

A

Pulmonary fibrosis-diagnostic tests

  • CT scan (honeycombing, loss of architecture, RETICULAR)
  • Lung biopsy may also be needed
43
Q

What can you see on chest X ray of pulmonary fibrosis?

What would you see on CT scan of pulmonary fibrosis?

A

Pulmonary fibrosis chest Xray

  • ↓Lung volume
  • Ground glass
  • Honeycomb lung (advanced disease)
44
Q

What would spirometry show in pulmonary fibrosis?

A

Pulmonary fibrosis

-Restrictive pattern i.e. FEV1/FVC > 0.7

45
Q

How do you manage a patient with pulmonary fibrosis?

A

Pulmonary fibrosis

  • Flu vaccination
  • Smoking cessation
  • Palliative care (oxygen, opiates for cough)
  • Lung transplant or DMARD Pirfenidone (anti-fibrotic)
46
Q

What are the causes of UPPER zone fibrosis?

A

Pulmonary fibrosis -Upper zone causes: CHARTS
C- Coal worker’s pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis

Lower lobe- MORE COMMON (e.g. asbestos and drugs, idiopathic fibrosis)

47
Q

Summarise the pathophysiology of sarcoidosis

A

Sarcoidosis
Formation of non-caseating granulomas within the lungs and lymphatic system

A granuloma is a collection of WBCs (mononuclear cells and macrophages) , surrounded by lymphocytes, plasma cells, mast cells, fibroblasts, and collagen

48
Q

What are the stages of chronic sarcoidosis based on CXR findings?

A

Sarcoidosis-chest x-ray staging
Stage 0 - normal findings (but positive bronchoalveolar lavage)

Stage I - bilateral hilar lymphadenopathy

Stage II - bilateral hilar lymphadenopathy + peripheral infiltrates (reticular or ground-glass opacities)

Stage III - peripheral infiltrates alone

Stage IV - pulmonary fibrosis (honeycombing)

49
Q

How does acute sarcoidosis present? Also, what syndrome is a subtype of sarcoidosis with an acute presentation and what are the main features?

A 
Acute sarcoidosis presents with Lofgren syndrome :
• FEVER plus 
1. POLYARTHRALGLIA (ankles common)
2. ERYTHEMA NODOSUM 
3. BILATERAL HILAR LYMPHADENOPATHY

(usually resolves spontaneously, good prognosis)

50
Q

What are the pulmonary symptoms of sarcoidosis?

A 
Sarcoidosis 
-Pulmonary symptoms
•progressive breathlessness and reduced exercise tolerance 
•dry cough 
•chest pain

(90% will have an abnormal CXR with bifilar lymphadenopathy +/- fibrosis

51
Q

What are some manifestations of chronic sarcoidosis?

  • constitutional
  • neurological
  • ocular
  • cardiac
  • abdominal
  • skin
  • bone
A

Sarcoidosis
• Constitutional: fatigue, weight loss, arthralgia, and low-grade fever. Peripheral lymphadenopathy is most frequent extra-pulmonary manifestation

  • Neurological: meningitis, peripheral neuropathy, bilateral Bell’s palsy
  • Ocular: uveitis, keratoconjunctivitis sicca, blurred vision
  • Cardiac: arrhythmias, restrictive cardiomyopathy (DO ECG)
  • Abdominal: hepatomegaly, splenomegaly, renal stones (↑Ca2+)
  • Skin: erythema nodosum, LUPUS PERNIO (purple skin lesions on nose, cheeks, chin, ears)
  • Bone – cysts in terminal phalanges (x-ray shows punched out lesions)
52
Q

What is the treatment for sarcoidosis?

A 
Sarcoidosis 
-patients with BHL alone won't need treatment as most resolve spontaneously 
-Steroids are indicated if:
  • Stage 2+ (not just for BHL) 
  • Parenchymal lung disease
  • ↑Ca2+
  • Neuro/CV/eye involvement

If severe disease: IV Methylprednisolone or immunosuppressants e.g. methotrexate/hydroxychloroquine

53
Q

What is the treatment for acute sarcoidosis?

A

Acute sarcoidosis

-treatment is Bed rest and NSAIDS

54
Q

Name some diseases that also feature non-caseating granulomas and are possible DDx for sarcoidosis

A
  • Hodgkin lymphoma - alcohol-induced pain, pruritis, hx of EBV, Reed-Sternberg cells
  • Non-Hodgkin lymphoma - lymphadenopathy, splenomegaly, bone marrow suppresion
  • Pneumoconiosis - exposure to mineral dust, chronic cough, progressive exertional dyspnoea
  • Granulomatosis with polyangiitis (Wegener’s) - chronic sinusitus with thick purulent discharge, treatment-resistant pneumonia, glomerulonephritis
55
Q

What is the gold standard test for diagnosis of sarcoidosis?

A

Bronchoscopy + biopsy - shows evidence of a non-caseating granuloma (DIAGNOSTIC ∆)

(can do for lung, liver, LN, skin, lacrimal)

56
Q

What bloods would you expect to see in sarcoidosis?

A 
Bloods 
-↑ESR
-lymphopenia
↑Ca2+ AND 24hr Urine - ↑Ca2+  
↑Ig
↑ACE 
↑LFTs
57
Q

What is Mikulicz synd – enlargement of parotid/lacrimal due to sarcoid, TB or lymphoma

A

Mikulicz synd- enlargement of parotid/lacrimal due to sarcoid, TB or lymphoma

58
Q

What is Heerfordt’s synd

A

Heerfordt’s synd aka. uveoparotid fever (caused by sarcoidosis)

  • parotid enlargement
  • fever
  • uveitis
59
Q

What is a lung abscess?

What causes lung abscess?

A

Lung abscess is a cavetating area of localised suppurative infection within the lung

Causes

  • inadequately treated pneumonia
  • aspiration (alcoholism/stroke/osophageal obstruction)
  • bronchial obstruction (foreign body/tumour)
  • pulmonary infarction
  • septic emboli (IV drug use/right sided endocarditis)
60
Q

What are the symptoms of lung abscess?

A

Lung abscess

  • SWINGING FEVER
  • Productive cough and FOUL smelling breath
  • ± Haemoptysis
  • Dyspnoea
  • Pleuritic chest pain
  • Empyema – develops in 20-30%
61
Q

Most common microbiological cause of lung abscess?

A

Lung abscess:

  • Staph.Aureus (gram +ve cocci in clusters)
  • Klebsiella (enteric, gram-ve rods in alcoholics + DM)

can also be TB, Fungal e.g. aspegillosis, Cryptococcus

62
Q

What would you see on CXR for lung abscess?

A

Lung abscess
CXR
-Walled cavity w/ air/fluid level
-May also show consolidation

Might want to do a CT to rule out obstruction

63
Q

Treatment of lung abscess?

A

Lung abscess

  • 4 to 6 weeks antibiotics (as directed by sputum culture)
  • Postural drainage or Aspiration may be needed
64
Q

What might you see on CXR of foreign body inhalation

A

Foreign body inhalation CXR

  • hyper-expansion (flattened diaphragms on affected side)
  • mediastinal shift AWAY
  • lobar or segmental atelectasis
65
Q

What are the classic risk factors for carbon monoxide poisoning?

A

CARBON MONOXIDE POISINING

  • Recent house move
  • Faulty/old boiler
  • House fire
  • Use of gas fire
  • BBQ in tent to warm up
  • Motor vehicle exhausts
  • Poorly ventilated areas
66
Q

How does carbon monoxide cause hypoxia?

A

The affinity of haemoglobin for CO is 240x stronger than for O2

  • Shift in O2 dissociation curve to the left, increasing affinity for O2 but decreasing release of O2 in tissue
  • Binding of CO to myoglobin leading to cardiac ischaemia and decreased cardiac output
67
Q

Presentation of carbon monoxide poisoning?

A

Carbon monoxide poisoning

  • Headache (90%)
  • Altered mental state (irritable, confusion, LOC, seizure, coma)
  • Parkinsonism features
  • Dizzy + Vertigo (50%)
  • Nausea + Vomiting (50%)
  • “Cherry Red” skin – see right (SEVERE)
  • Signs of burns (soot in nostrils/facial burns/stidor/hoarsenss/drooling/↓GCS EARLY INTUBATION

*Can get encephalopathy 2-6 wks after

68
Q

How do you diagnose carbon monoxide poisoning?

A

Carbon monoxide poisoning
-Abnormal COHb level on venous/arterial CO oximetry on ABG/VBG
>3% in non-smokers
>10% in smokers

(pulse oximeters cannot distinguish between COHb and oxyhaemoglobin so sats will appear normal!)

-Also do ECG -myocardial ischaemia (ST depression, VT or VF!)

69
Q

What is the management for carbon monoxide poisoning?

A

Carbon monoxide poisoning
-Secure airway if necessary (especially if signs of burns)

  • 100% Oxygen immediately via NRBM - continue giving until patient is asymptomatic for at least 6 hours and COHb level normalises (<3% non smokers and <10% for smokers)
  • give hyperbaric oxygen if LOC, neuro signs, MI/arrhyth, preg
70
Q

What is the classic picture of a patient with sleep apnoea?

A

Sleep apnoea

  • Obesity (especially around neck)
  • Loud snoring
  • Daytime somnolence (poor sleep quality)
  • Morning headache
  • Decreased libido
  • Reduced cognitive performance

Risk factors: smoking/sedatives, beta blockers or alcohol before bed/FH/hypothyroisism /structural abnormalities
○ Adenotonsillar hyperplasia - in children
○ Nasal septum deviation
○ Enlarged uvula, tongue, soft palate
○ Overbite with small chin
○ Neuromuscular disease

71
Q

What is the gold standard test for sleep apnoea?

A

Sleep apnoea
Polysomnography:
- ECG, EMG (muscle movement)

72
Q

How many apnoeas per hour is diagnostic?

A

Sleep apnoea
-At least 5 apnoeas (>10 seconds without breathing) per hour + symptoms = diagnostic

Mild OSA = 1-14/hour
Moderate OSA = 15-30/hour
Severe OSA = >30/hour

73
Q

Management of sleep apnoea?

A

Management of sleep apnoea?

  • Weight loss (most effective)
  • Avoid alcohol and smoking
  • CPAP at night for moderate disease
  • Surgery to remove structural problem

5thyr (18 decks)

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