Resp Flashcards
What are the different divisions of a pleural effusion? (6)
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
What causes a transudative pleural effusion?
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
What causes an exudative effusion?
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)
How does a pleural effusion present? (symptoms)
PLUERAL EFFUSION
Small pleural effusions (<300ml) are often asymptomatic
OR
- Dyspnoea SOB
- Pleuritic chest pain
What signs do you get in pleural effusion? (general exam/palpation/percussion/auscultation)
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
What can be seen on a chest x-ray in pleural effusion?
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
What is used to diagnose pleural effusion?
How do you do it?
Diagnotic thoracentesis/pleurocentesis
-Percuss upper border of pleural effusion and choose a site 1 or 2 intercostal spaces below it
What cytology results would indicate what in pleural fluid analysis? (neutrophils/lymphocytes/mesothelial cells, abnormal mesothelial cells/giant multinucleated cells)
Neutrophils ++
- Pneumonia
- PE
Lymphocytes ++
- Malignancy
- TB
- RA, SLE, sarcoidosis
Mesothelial cells ++
- Pulmonary infarction
Abnormal mesothelial cells
-Mesothelioma
Giant multinucleated cells
- RA
What would raised amylase suggest in thoracentesis ?
Raised amylase in thoracentesis: pancreatitis or osophageal rupture (could also mean carcinoma or bacterial pneumonia)
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?
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
What is the management of pleural effusion?
Management of Plueral effusion
- manage the underlying cause
- Drainage (aspiration or chest drain)
What would you expect to see in an empyema? (Ph, LDH, glucose)
How do you treat an empyema?
Empyema
- pH LOW
- LDH high
- glucose LOW (being used up by bacteria)
Treatment: chest drain under USS guidance and antibiotics
What investigation should you do fit pleural fluid analysis is inconclusive?
PLEUARL EFFUSION
-Do a percutaneous Pleural biopsy – if fluid analysis is inconclusive
What are complications of a chest drain?
Chest drain
- can cause PULMONARY ODEMA - drain slowly (0.5-1.5L/24hrs)
- never drain >1.5 litres
Treatment for recurrent pleural effusions?
Treatment for repeated pleural effusions
-Pleurodesis- stick visceral and parietal layers together
(with tetracycline, Bleomycin or sterile talc)
What causes pleural mesothelioma?
Asbestos exposure
What are the most common symptoms of pleural mesothelioma?
Investigation?
Shortness of breath Chest pain (non-pleuritic)
Thoracoscopy biopsy with stained biopsy - mesothelioma cells and psammoma bodies (looks like an onion)
In which patients does TB commonly occur? (4)
- FOREIGN TRAVEL
- HIV/immunocompromised
- In those with an infective contact (always ask about infection in home contacts, this is most common cause for chilldren)
How do we manage contact preventing in cases of TB?
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
After the initial inhalation of TB aerosol, what happens then? (2 options)
TB inhalation
- ~70% clear the infection
- ~30% get primary TB (classified by GOHNS focus)
People with primary TB, what happens then?
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)
What are the possible symptoms of TB?
- pulmonary
- CNS
- Cardiac
- GU
- Bones/joints
- Skin
- General
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
What investigations would you do for TB?
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)
- Can also do PCR (see if resistant)
- Can also do biopsy and histology
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?
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
When would you get false negatives of mantoux test?
False negatives of mantoux test
- weakened immune system (cant react)
- really recent TB infection (within 10 weeks)
What TB test is NOT affected by previous infection?
What does a positive test mean?
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)
What area of the lung does TB normally affect?
TB affects upper lobe
What is milary TB?
What patients are most likely to get milary TB?
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
What is the treatment of ACTIVE TB?
ACTIVE TB treatment ‘RIPE’
- RIFAMPACIN
- ISONIAZID (and pyridoxine)
- PYRAZINAMIDE
- ETHAMBUTOL
TOTAL of 6 months
2 months of RIPE
4 months pf RI
*corticosteroids as adjunct
What is the treatment for LATENT TB?
LATENT TB (not always treated as 5-10% will get reactivation)
-6 months isoniazid
OR
-3 months of rifampicin + isoniazid
What are the side effects of rifampicin?
RIFAMPICIN (crap GPs neumonic)
• P450 inducer (COCP, warfarin, statin inactivation)
• Liver toxicity (monitor LFTs)
• Orange urine
What are the side effects of isoniazid?
ISONIAZID (sick faces neumonic) • Peripheral neuropathy - give pyridoxine to prevent this • P450 inhibitor • SLE-like symptoms • Liver toxicity (monitor LFTs)
What are the side effects of pyrazinamide?
PYRAZINAMIDE
• may precipitate gout (hyperuriceamia)
• Liver toxicity (monitor LFTs)
What is the main side effect to be aware of of ethambutol?
ETHAMBUTOL
•Optic neuritis - red/green colourblindness and peripheral vision STOP
What would you see on LP of TB meningitis?
TB meningitis
fibrin, lymphocytes, ↓glucose, ↑protein
What is the treatment of TB meningitis?
Treatment of meningitis TB
-2 months of RIPE (rifampicin, isoniazid, pyrazinamide, ethambutol)
-1 YEAR of RI
(plus Dexamethasone)
What pathological features are there in pulmonary fibrosis?
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)
What are some risk factors for developing pulmonary fibrosis?
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
Symptoms of pulmonary fibrosis?
Pulmonary fibrosis (often affects patients >45 years)
- Dry cough
- Exertional dyspnoea (persistant and progressive)
- Flu like symptoms (malaise, arthralgia)
- Weight loss
What signs would you see on examination of pulmonary fibrosis?
Pulmonary fibrosis signs
- Cyanosis central or peripheral
- Clubbing in 50%
- BILATERAL FINE END INSPIRATORY CREPS
- Decreased chest expansion
What are the main complications of pulmonary fibrosis?
Pulmonary fibrosis complications
- Respiratory failure
- Increased risk of lung cancer
**3-4 year life expectancy
What are the diagnostic tests for pulmonary fibrosis?
Pulmonary fibrosis-diagnostic tests
- CT scan (honeycombing, loss of architecture, RETICULAR)
- Lung biopsy may also be needed
What can you see on chest X ray of pulmonary fibrosis?
What would you see on CT scan of pulmonary fibrosis?
Pulmonary fibrosis chest Xray
- ↓Lung volume
- Ground glass
- Honeycomb lung (advanced disease)
What would spirometry show in pulmonary fibrosis?
Pulmonary fibrosis
-Restrictive pattern i.e. FEV1/FVC > 0.7
How do you manage a patient with pulmonary fibrosis?
Pulmonary fibrosis
- Flu vaccination
- Smoking cessation
- Palliative care (oxygen, opiates for cough)
- Lung transplant or DMARD Pirfenidone (anti-fibrotic)
What are the causes of UPPER zone fibrosis?
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)
Summarise the pathophysiology of sarcoidosis
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
What are the stages of chronic sarcoidosis based on CXR findings?
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)
How does acute sarcoidosis present? Also, what syndrome is a subtype of sarcoidosis with an acute presentation and what are the main features?
Acute sarcoidosis presents with Lofgren syndrome : • FEVER plus 1. POLYARTHRALGLIA (ankles common) 2. ERYTHEMA NODOSUM 3. BILATERAL HILAR LYMPHADENOPATHY
(usually resolves spontaneously, good prognosis)
What are the pulmonary symptoms of sarcoidosis?
Sarcoidosis -Pulmonary symptoms •progressive breathlessness and reduced exercise tolerance •dry cough •chest pain
(90% will have an abnormal CXR with bifilar lymphadenopathy +/- fibrosis
What are some manifestations of chronic sarcoidosis?
- constitutional
- neurological
- ocular
- cardiac
- abdominal
- skin
- bone
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)
What is the treatment for sarcoidosis?
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
What is the treatment for acute sarcoidosis?
Acute sarcoidosis
-treatment is Bed rest and NSAIDS
Name some diseases that also feature non-caseating granulomas and are possible DDx for sarcoidosis
- 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
What is the gold standard test for diagnosis of sarcoidosis?
Bronchoscopy + biopsy - shows evidence of a non-caseating granuloma (DIAGNOSTIC ∆)
(can do for lung, liver, LN, skin, lacrimal)
What bloods would you expect to see in sarcoidosis?
Bloods -↑ESR -lymphopenia ↑Ca2+ AND 24hr Urine - ↑Ca2+ ↑Ig ↑ACE ↑LFTs
What is Mikulicz synd – enlargement of parotid/lacrimal due to sarcoid, TB or lymphoma
Mikulicz synd- enlargement of parotid/lacrimal due to sarcoid, TB or lymphoma
What is Heerfordt’s synd
Heerfordt’s synd aka. uveoparotid fever (caused by sarcoidosis)
- parotid enlargement
- fever
- uveitis
What is a lung abscess?
What causes lung abscess?
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)
What are the symptoms of lung abscess?
Lung abscess
- SWINGING FEVER
- Productive cough and FOUL smelling breath
- ± Haemoptysis
- Dyspnoea
- Pleuritic chest pain
- Empyema – develops in 20-30%
Most common microbiological cause of lung abscess?
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
What would you see on CXR for lung abscess?
Lung abscess
CXR
-Walled cavity w/ air/fluid level
-May also show consolidation
Might want to do a CT to rule out obstruction
Treatment of lung abscess?
Lung abscess
- 4 to 6 weeks antibiotics (as directed by sputum culture)
- Postural drainage or Aspiration may be needed
What might you see on CXR of foreign body inhalation
Foreign body inhalation CXR
- hyper-expansion (flattened diaphragms on affected side)
- mediastinal shift AWAY
- lobar or segmental atelectasis
What are the classic risk factors for carbon monoxide poisoning?
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
How does carbon monoxide cause hypoxia?
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
Presentation of carbon monoxide poisoning?
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
How do you diagnose carbon monoxide poisoning?
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!)
What is the management for carbon monoxide poisoning?
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
What is the classic picture of a patient with sleep apnoea?
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
What is the gold standard test for sleep apnoea?
Sleep apnoea
Polysomnography:
- ECG, EMG (muscle movement)
How many apnoeas per hour is diagnostic?
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
Management of sleep apnoea?
Management of sleep apnoea?
- Weight loss (most effective)
- Avoid alcohol and smoking
- CPAP at night for moderate disease
- Surgery to remove structural problem
