resp from Kelly's ppt Flashcards
describe the characteristics of a squamous cell Lung Ca
may px as obstructive lesion leading to infection
occasionally cavitates
local spread is common
widespread mets occur LATE
secrete PTH - hypercalcaemia
STRONGLY assoc with finger clubbing
describe the characterisitc features of a large cell lung Ca
met early
often peripheral in lungs
anaplastic (poorly differentiated) tumours with a poor prognosis
may secrete B-HCG
features of a lung adenocarcinoma???
associated with asbestos exposure
most common Lung Ca assoc with asbestos exposure - but most who get it are smokers…
features of small cell lung cancer
how would you manage it?
often metastatic at Dx
causes (almost all) the weird syndromes -
ectopic ADH secretion - SIADH and hyponatraemia
ACTH secretion - Cushings
Lambert-eaton syndrome - antibodies to the voltage gated Ca2+ channels causing a myathenic syndrome (that is sort of the opposit of M.Gravis - ie movements are initially helped by doing them a bit more…)
- PX with proximal muscle weakness / reduced tendon reflexes.
managment of SCLC?
most will be with chemo + radio
some with very early stage disease - considered for surgery;..
what symptoms can a pancoast tumour cause..?
think apical tumour…..
- horner’s syndrome (pre-ganglionic) - TRIAD OF: anhidrosis of face/ meiosis / ptosis of eyelid or apparent enopthalmos)
- local nerve effects - Ipsilateral reflex sympathetic dystrophy in arm (increased sensitivity to touch / skin changes etc..)
- Brachial plexus invasion - (C8-T1) - wasting of the intrinsic hand muscles / parasthesiae on medial side of arm
- unilateral recurrent laryngeal nerve palsy - hoarse voice etc..
rarely:
oedema in arm / SVC obstruction 2y to compression of blood vessels….
palliative trreatment options for symptomatic management of lung cancer…
If airway narrowing symptomatic:
- endoscopic laser therapy
- transbronchial stenting
malignant pleural effusions?
- aspirate to dryness
- give sclerosing agent eg. tetracycline / belomicinm in pleural space
general QOL?
- counselling
- opiates
- benzos for anxiety due to breathlessness? - eg. use lorazepam.
features of a bronchial carcinoid tumour?
neuroendocrine ecreting cells - so the standard carcinoid syndrome stuff
recurrent hamoptysis
can also make ACTH sometimes - Cushing’s syndrome
how do you investigate suspected active tb?
and what would the investigations show?
how would you screen for latent tb?
CXR - might show cavitationin the upper lobes / mediastinial or hilar lymphadenopathy /pleural effusion
3 sputum samples - spontaneously produced deep cough symptoms -
- send for microscopy - acid fast bacilli (sputum smear microscopy is the fast one..)
- NAAT testing (for quick results)
- mycobacteria culture (weeks…)
HIV test all
screening for latent TB:
1. Mantoux test:
tuberculin injected intradermally - inspect for signs of skin reaction after 2-3 days
- Interferon gamma release assay test
RAPID RESULT
more reliable
use in under-served groups etc.
tx with 6 months isoniazid with pyroxidine
what are the side effects of: rifampicin isoniazid pyrazinamide ethambutol
R - liver and secretions (S+L=R)
I - p neuropathy (prevent with pyridoxine) + haemo
P - rheumatoid stuff (gout / arthralgia / rash)
E - eyes - optic neuritis and colour blindness
features of pneumoccal pneumonia in particular?
high fever
rapid onset
herpes labialis (cold sores)
pleuritic chest pain
URINARY ATG TEST FOR PNEUMOCCOCUS
who gets h. influenzae pneumonia
COPD pts
who gets s auerus pneumoniae
post influenza
feATURES of mycoplasma pneumonia
dry cough
atyipcal CXR findings
AIHA as well?
erythema multiforme?
legionella pneumonia features?
hyponatraemia
lymphopenia
URINARY ATG TEST FOR LEGIONELLA
who gets klebsiella pneumonia?
alchoholics?
who gets pneumocystis pneumonia and what are the signs?
hiv patients
dry cough
exercise induced desaturations
lack of chest signs
management of CAP
- amox is first line for mild CAP (or erythomicin if pen-allergic)
- if mod - can use amox + erythomicin / clarithromicin
- if mod-severe can use co amoxiclav + erythromicin or another macrolide to cover for the atypicals…)
management of HAP
If non-severe - 1. Co-amoxiclav ORAL
If severe / at high risk of resistance - Ceftriaxone IV + Vancomycin IV if suspecting MRSA infection…
treating aspiration pneumonia
Ceftriaxone (other cephalosporins ok)
+ Metronidazole
patient presents with ENT, respiratory and kidney involvement - what do you suspect (or what do you have to rule out…)
wegener’s granulomatosis
describe the three stages of churg-strauss syndrome:
- ALLERGY
patients ahve asthma / allergic rhinitis / nasal polyps
- EOSINOPHILIA
- VASCULITIS
- small/medium vessel vasculitis
- damage to kidneys / lungs, the digestive tract and most dangerously, the heart.
may have associated petechial rash
pANCA antibodies often detected
may be precipitated by LTRAs
what are the two first line treatments for OSA?
weight loss
obstructive sleep apneoa
common cause of pneumonia in bird keepers?
Chlamydia psittaci is a cause of pneumonia in bird keepers
what test should you do before starting azithromicin?
ECG to rule out prolonged QT
baseline LFTs
pleural inflammation (and fluid collection) in response to infection (usually pneumonia but can also be BE / abcess) can be described in terms of:
simple parapneumonic effusion
complicated parapneumonic effusion
empyema
simple - no infection
compicated -infection has spread to the pleural space
empyema - frank pus in the pleural space
what is a lung abcess?
a cavitating area of localised suppurative (pus producing) infection within the lung…
what are the causes of a lung abcess?
inadequaetly treated pneumonia aspiration bronchial obstruction aspiration pulmonary infarct / emboli
swinging fever and chest signs?
LUNG ABCESS! cough purulent foul smelling sputum pleuritic chest pain haemoptysis clubbing malaise wt loss
major or minor PE - how do you decide?
minor tends to be peripheral with just a bit of pleuritic chest pain…
MAJOR tends to be central - signs of shock / imminent circulatory collapse / hypoxia / central chest pain
what would progressive exertional dyspnoea + lethargy + fatigue make you suspect?
PAH
(but pretty much sounds like many HF style things..)
may also have: extertional syncope exertional chest pain periph oedema weakness
what is the management of PAH?
- treat the underlying cause
- oxygen
- anticoagulation
THEN:
acute vasodilator therapy dictates where to go next - if the vasodilator therapy shows a signficant fall in PA pressure post vasodilator administration eg. with NO - then can treat with Ca2+ channel blockers (though this is the minority of patients…)
if negative response to acute vasodilator test:
- prostacyclin analogues - treprostinil / iloprost
- endothelin receptor antagonists - bosantan
PDEis - sildenafil
if progressive Sx - heart lung transplant..
what is the ‘double burden’ of lung infections that patients with HIV suffer with
- increased susceptibility to pneumonia regardless of CD4 count
just more likely to get them… - opportunistic infections with a low CD4 count
eg. PCP
how would you describe interstitial lung disease?
what are the causes of upper lobe ILD?
what are the causes of lower lobe ILD?
what must you ensure in phyical examination and what might you find…?
what Ix in ILD?
what bloods in particular for ILD?
a problem of gas echange betweeen the capillaries and the alveoli..
Upper:
CHARTS
(coal workers’ / EAA / Radiation / TB / Sarcoid)
Lower:
IPF
CTDs
Drugs
OE: - full body for systemic disease
clubbing
fine end insp crackles
skin eye joints for systemic disease
Ix: Pulmonary function tests - restrictive pattern / low gas transfer / low to normal PaCO2 Blood tests High res CT scan Bornco-alveolar lavage
FBC – eosinophilic pneumonia
U&Es – Wegener’s
Total IgE – eosinophilic pneumonia
Aspergillus and avian precipitins (ABPA, EAA)
ACE (Sarcoid)
ANA, ENA, dsDNA, Rh factor (rheum disease)
ANCA (Wegener’s)
non-caseating granuloma in a young adult of african descent - what do you think…?
Sarcoidosis
diagnostic criteria for ARDS
acute onset (w/in 1wk of known RF)
pulmonary oedema - bilateral infiltrates on CXR not FULLY explained by effusions / lobarcollapse etc….
Non-cardiogenic
PULMONARY ARTERY EDGE PRESSURE IF IN DOUBT…
Hypoxaemia
