Resp1 Flashcards
Cough
What is bronchiectasis?
Increased mucus production and permanent dilation of the bronchi secondary to an underlying cause
Which organisms commonly cause bronchiectasis?
H influenzae
S pneumoniae
S aureus
P aeruginosa
What are some common causes of bronchiectasis?
Cystic fibrosis Ciliary dyskinesia Alpha 1 anti-trypsin deficiency Obstruction Immunosuppression Childhood viral infx Aspergillus fumigatus
What are the symptoms of bronchiectasis?
Persistent cough
Green/rusty cough
SOB
Haemoptysis
What are the signs of bronchiectasis?
Crackles on auscultation
Squeaks/pops on inspiration
Signs of underlying disorder
Fever
What investigations would you do on a Pt with bronchiectasis?
CXR (first line)
High res CT (gold standard/most appropriate)
Observations (hypoxia)
FBC (raised WCC)
Sputum culture
Pulmonary function (dec FEV1, inc RV/TLC)
Serum alpha-1 antitrypsin levels
Sweat NaCl concentration and genetic testing for CFTR
What will you see in a CXR and CT in bronchiectasis?
CXR- dilated thickened walls
CT- signet ring sign
What is the management of a Pt with bronchiectasis?
Exercise and nutrition
Airway clearance therapy (postural drainage/percussion)
Inhaled bronchodilator (salbutamol)
Inhaled hyperosmolar agent (hypertonic saline)
ABx
What is the prognosis of a Pt with bronchiectasis?
Irreversible
Depends on the severity and recurrence of exacerbations
What are the complications of a Pt with bronchiectasis?
Haemoptysis
Respiratory failure
Cor pulmonale
What is pneumonia?
Inflammation of the lung parenchyma caused by bacteria, virus, or fungi, resulting in fluid/pus air sacs
What are the three types of pneumonia?
Community acquired pneumonia
Hospital acquired pneumonia
Aspiration pneumonia
What are the common causes of CAP?
Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus
What are the common causes of HAP?
Pseudomonas aeruginosa
Escherichia coli
Klebsiella pneumoniae
MSSA
What are the common causes of atypical pneumonias?
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionalla pneumophila
Coxiella burnetti
What are the mechanisms of entries for pneumonia?
Inhalation (viral/atypical)
Aspiration of URT secretions
Haematogenous from local infx (endocarditis)
Direct extension from local foci (TB via lymphatics)
What are the symptoms of pneumonia?
Productive cough with coloured sputum
SOB
Pain on inspiration (pleuritic)
What are the signs of pneumonia?
Fever Confusion Dull percussion Increased fremitus Bronchial breathing
What are the main investigations for pneumonia?
CXR- area of consolidation
FBC- raised WCC
Sputum sample- MC and S
Blood cultures- if severe
What is the scoring system for pneumonias?
CURB-65
What is CURB-65?
Confusion Urea >7 Resp rate >=30 Blood pressure (S<90, D<=60) Age >=65
What should you do for a Pt with a CURB-65 of 0-1?
Treat at home
What should you do for a Pt with a CURB-65 of 2?
Consider hospital treatment
What should you do for a Pt with a CURB-65 of 3+?
Severe pneumonia, treat in ITU
What should you treat a low severity pneumonia with?
Oral amoxicillin
What should you treat a medium severity pneumonia with?
Oral/IV amoxicillin + macrolide (clarithromycin)
What should you treat a high severity pneumonia with?
IV co-amoxiclav + macrolide (clarithromycin)
What should you after giving a Pt with pneumonia antibiotics?
Repeat CXR in 6 weeks
What is the prognosis of a CURB-65 of 0-1?
30 day mortality <1%
What is the prognosis of a CURB-65 of 2?
30 day mortality 5-15%
What is the prognosis of a CURB-65 of 3+?
30 day mortality 20-50%
What are the complications of pneumonia?
Septic shock
C difficile from ABx use
HF/resp failure in elderly
How is Legionella transmitted?
Via aqueous environments such as air conditioners and contaminated water supplies
What is the difference between Legionnaire’s disease and Pontiac fever?
LD- Legionella pneumonia
PF- non-pneumatic Legionella
What are the symptoms of a Legionella pneumonia?
Prodromal flu-like symptoms (fever, malaise, myalgia)
Dry cough, can become productive
Nausea, DnV
Why are atypical pneumonias different from typical pneumonias?
They cannot be detected by Gram stains and cannot but cultured by standard methods
What investigations would you do for a Legionella pneumonia?
Sputum culture
Urinary antigen detection
U+E- hyponatraemia
CXR- bibasal consolidation
What is the treatment for a Legionella pneumonia?
IV fluoroquinolones OR macrolides
eg. ciprofloxacin OR clarithromycin
What are the characteristics of a Pneumocystis jirovecii infection?
Opportunistic fungal infx
AIDS defining illness
What is the treatment for a Pneumocystis jirovecii infection?
high dose Co-trimoxazole
What are the characteristics of a Pseudomonas aeruginosa infection?
Seen in Pts with bronchiectasis/CF
What is the treatment for a Pseudomonas aeruginosa infection?
Treat with piptazobactam (piperacillin + tazobactam)
What is the presentation of Mycoplasma pneumonia?
Insidious onset
Persistent cough
Low grade fever
From a close community setting
What is seen in the blood film of a Mycoplasma pneumonia infection?
Red cell/cold agglutinins
What is the treatment for a Mycoplasma pneumonia infection?
Erythromycin/clarithromycin
What type of Pt often presents with a Staph aureus infection?
IVDU
What is seen in a CXR of a Pt with a Staph aureus infection?
Patchy consolidation
Forms abscesses
What is the treatment for a Staph aureus infection?
Flucoxacillin
What is the treatment for an MRSA infection?
Vancomycin
What is the modality of transport for TB?
Aerosol droplets
What are the two conditions required for a Pt to present with TB?
Infection of Mycobacterium tuberculosis
Inadequate immune system
What are the risk factors for TB?
Recent travel to Asia, Latin America, or Africa
Immunosuppression
Malnutrition
Alcoholism
What is the pathophysiology of TB?
Droplets enter the lungs
Macrophages + T lymphocytes contain the infection, forming a granuloma
In weak immune systems, the infection escapes
What are the symptoms of TB?
Cough for 2-3 weeks
From dry to wet
FLAWS especially S
Haemoptysis in <10%
What are the signs of TB?
Fever
Crackles
Bronchial breathing
Erythema nodosum
What are the investigations you should do for TB?
Obs CXR Sputum smear Sputum culture Nucleic acid amplification test (NAAT) Biopsy- caseating granulomas
What are the 3 buzzwords for a TB sputum smear?
Acid fast bacilli
Ziehl-Neelson staining
Lowenstein-Jensen agar
What are the types of lung cancer?
Small cell (20%)
Non-small cell (80%)
-Adenocarcinoma (45% of NSCLC, peripheral in lungs)
-Squamous cell carcinoma (25-30%, later mets)
-Large cell carcinoma (10%, central)
Metastases
Mesothelioma
What are the risk factors for lung cancer?
Smoking
Exposure to tobacco smoke, radon gas, asbestos
COPD
Facts about lung cancer epidemiology
Most common cause of cancer mortality worldwide
3rd most common cancer in Europe
What are the characteristics of small cell carcinomas?
Strongest association with smoking
Arise in central lung
Rapid growth, highly malignant
May secrete ectopic hormones (ATCH/ADH)
What are the characteristics of adenocarcinomas?
Most common lung cancer in non-smokers
Most common lung cancer in females
Arise in peripheral lung
Most have pleural involvement
What are the characteristics of squamous cell carcinomas?
Most common lung cancer in male smokers
Strong association with smoking
Arise in central lung
Can produce PTHrP
What are the characteristics of large cell carcinomas?
Can arise centrally or peripheral
Poor prognosis
What are the symptoms of a Pt with lung cancer?
FLAWS
SOB
Cough
Haemoptysis
What signs can you find in a Pt with lung cancer?
Horner's syndrome Cachexia Anaemia Clubbing Paraneoplastic syndromes Wheeze, crackles, dull percussion, reduced breath sounds
What investigations would you do on a Pt with lung cancer?
Obs CXR CT Sputum cytology (assessment of lung secretions) Bronchoscopy Biopsy (for definitive diagnosis)
What would you see in a CXR of a SCLC?
Central mass
Hilar lymphadenopathy
Pleural effusion
What would you see in a CXR of a NSCLC?
Single/multinodular nodes
Pleural effusion
Lung collapse
Mediastinal/hilar fullness
What is a mesothelioma?
An aggressive epithelial neoplasm arising from the lining of the lung, abdomen, pericardium, or tunica vaginalis
Which environmental exposure puts people at risk of developing a mesothelioma?
Asbestos
What 2 conditions can be caused by asbestos exposure?
Asbestosis
Mesothelioma
What is asbestosis?
Diffuse interstitial fibrosis
Due to inhalation of asbestos fibres
What is the difference between asbestosis and asbestos-induced mesothelioma?
Asbestosis- asbestos fibres deposited in the alveoli
Mesothelioma- asbestos fibres deposited in the lining of the lungs
Which of the two (asbestosis and asbestos-induced mesothelioma) has a stronger correlation with smoking?
Asbestosis
What are the risk factors for a mesothelioma?
Asbestos exposure (shipyard/construction workers)
What are the symptoms and signs for a mesothelioma?
Dry cough
SOB
Muffled breath on auscultation (due to pl effusion)
What are the investigations for a mesothelioma?
CXR
CT
What findings would you see in a CXR/CT of a Pt with mesothelioma?
Thickened pleural plaques
Fibrosis
Honeycomb appearance
25F presents to A&E with 2/7 Hx of productive cough, SOB and fever. The cough is worse at night. She has brought up green mucus 2/7. O/E you hear crackles throughout. Her PMHx is cystic fibrosis at birth and has had similar symptoms in the past.
What is the most likely diagnosis?
A. Asthma
B. Pneumonia
C. Chronic sinusitis
D. Bronchiectasis
D. Bronchiectasis
Resp symptoms, mucus, Hx of CF
All leads to bronchiectasis being the most likely.
25F presents to A&E with 2/7 Hx of productive cough, SOB and fever. The cough is worse at night. She has brought up green mucus 2/7. O/E you hear crackles throughout. Her PMHx is cystic fibrosis at birth and has had similar symptoms in the past.
What is the first line investigation for this patient?
A. Bloods (FBC, CRP)
B. CXR
C. CT
D. Pulmonary function
B. CXR
Everyone with these symptoms should get a CXR as a first line investigation. CT is the gold standard but only used when you have a high suspicion of bronchiectasis.
50M smoker with diabetes + HTN presents to A&E with 1/7 confusion and productive cough with yellow sputum. O/E he is apyrexial, BP 150/95 mmHg, HR 90 bpm, RR of 20 breaths per min. His oxygen saturation is 96% at rest. There are crackles at the left base. His urea is 5 mmol/L.
What is the most likely causative organism in this case?
A. Staphylococcus aureus B. Mycoplasma pneumoniae C. Streptococcus pneumoniae D. Pseudomonas aeruginosa E. Legionella pneumophila
C. Streptococcus pneumoniae
50M smoker with diabetes + HTN presents to A&E with 1/7 confusion and productive cough with yellow sputum. O/E he is apyrexial, BP 150/95 mmHg, HR 90 bpm, RR of 20 breaths per min. His oxygen saturation is 96% at rest. There are crackles at the left base. His urea is 5 mmol/L.
How should we treat this patient?
A. Admit and give IV co-amoxiclav + macrolide
B. Admit and give oral amoxicillin
C. Admit for observations
D. Give him a smoke cessation leaflet
E. Send home with oral amoxicillin and advise to return if he becomes severely unwell
E. Send home with oral amoxicillin and advise to return if he becomes severely unwell
His CURB-65 score is only 1, due to the confusion.
