Respiration Flashcards
What is COPD
progressively worsening and irreversible airflow limitation
what are types of COPD
chronic bronchitis
emphysema
A1AT deficiency
what are risk factors for COPD
cigarettes
air pollution
genetics - A1AT deficiency
older males
what organisms cause infective exacerbations in COPD
H.influenza
S.pneumonae
what is the pathophysiology of chronic bronchitis
Hypertrophy and hyperplasia of mucous glands
chronic inflammation cells infiltrate bronchi and bronchioles causing luminal narrowing
there is mucus hypersecretion, ciliary dysfunction and narrowed lumen, increasing infection risk and air trapping.
BLUE BLOATER
what are symptoms for chronic bronchitis
cough for 3 + months, over 2 + years with sputum
what is emphysema
destruction of elastin layer in alveolar ducts/sacs and respiratory bronchioles
- reduced elastin causes air trapping distal to blockage (large air sacs = BULLAE)
what are different kinds of emphysema
centriacinar emphysema (resp. bronchioles only)
Panacinar emphysema (resp. bronchioles, alveolar and alveolar sacs)
Distal acinar
Irregular
who is likely to get centriacinar emphysema
smokers
who is likely to get panacinar emphysema
A1AT deficiency
what is A1AT deficiency
an autosomal codominant interited condition
what is the pathophysiology of A1AT deficiency
there is a reduced A1 antitrypsin leading to an increase in neutrophil elastase which causes damage to the elastin layer in the lungs, leading to panacinar emphysema as well as liver issues
what is the normal function of A1 antitrypsin
it degrades neutrophil elastase thus protecting excess damage to elastin layer especially in the lungs
when do you suspect A1AT deficiency
in younger/middle aged men with COPD symptoms but no smoking history
what are symptoms of COPD
typically in an older patient
chronic cough
purulent sputum - increased infection risk
extensive smoking history
constant dyspnoea
what is a blue bloater cough
chronic purulent cough, dyspnoea, cyanosis and obesity
what conditions do you get blue bloater
chronic bronchitis
what is pink puffer in COPD
minimal cough with pursed lip breathing, cachectic, barrel chest and hyperresonant percussion
what conditions do you see pink puffer in
emphysema
what is the dyspnoea grading scale
MRC 1-5
1 - strenuous exercise
5 - cant do daily activities without shortness of breath such as changing clothes
what are the main pathogens in acute COPD exacerbations
S. pneumo
H. influenzae
how do you diagnose COPD
Pulmonary function test
Fractional expired nitrogen
FEV1:FVC <0.7
Obstruction on PFT spirometry
DLCO
genetic testing
ABG/ECG/CXR
Is COPD bronchodilator reversible
no
In COPD what change occurs to FEV1
FEV1 decreases in COPD
what lung condition is reversible with bronchodilators
asthma
What impact does asthma have on FEV1
Decrease in FEV1
what is DLCO
it is the diffusing capacity of CO across the lung
what happens to the DLCO in COPD
it is low
What happens to the DLCO in asthma
it is normal
what is a complication of COPD
Cor polmonale and increased infection risk
how do you treat COPD
SMOKING CESSATION
Vaccine
1. SAB2A (Salbuterol)
2. SAB2A + LAB2A (salmeterol) and LAMA3 (tiotropium)
3. SAB2A, LAB2A, LAM3A, ICS
consider long term oxygen if very severe
what is an acute COPD exacerbation
O2 target is 88-92% saturation
excess o2 increases deadspace and therefore the V/Q ratio will become mismatched and increased CO2 retention
how do you treat an acute COPD exacerbation
Nebulised salbutamol and ipratropium bromide
ICS
antibiotics
what is asthma
it is a chronic reversible airway disease characterised by reversible airway obstruction, airway hyperresponsiveness and inflamed bronchioles
what are types of asthma
Allergic - 70%
Non allergic - 30%
What is allergic asthma
it is IgE mediated anis due to an environmental trigger
Genetics should be considered here and the hygiene hypothesis
What are environmental triggers of asthma
Pollen
Smoke
Dust
Mold
Antigens
what is Non allergic asthma
this is non IgE mediated it is intrinsic
may present later in life and is harder to treat
what are triggers for asthma
Infection
Allergens
Cold weather
exercise
drugs
what is the hygiene hypothesis
when you grow up with high level of hygiene it causes you to have an increased susceptibility to asthma infection
what is the atopic triad
atopic rhinitis
asthma
eczema
what is samters triad
nasal polyps
asthma
aspirin sensitivity
what is the pathophysiology of asthma
- Over expressed TH2 cells in airways are exposed to a trigger
- TH2 cytokine release (IL3, 4, 5, 13) and leads to IgE production and eosinophil recruitment
- Mast cell degranulation and release of toxic proteins leads to bronchial constriction and mucus hypersecretion
what happens overtime in asthma
there is chronic remodelling which leads to bronchial scarring, recued lumen size and increased mucus
what are symptoms of asthma
wheeze
cough - typically dry
chest tightness
shortness of breath
episodic symptoms when exposed to triggers
what are asthmatic episodes classed as
moderate
severe
life threatening
what is PEF in a moderate asthma episode
50-75%
what is PEF in a severe asthma episode
35-50%
what is PEF in a life threatening asthma episode
lower than 33%
how do you diagnose asthma
spirometry
increased FeNO
FEV1: FVC <0.7
what is the treatment for chronic asthma
- SAB2A
- SAB2A + ICS
- SAB2A + ICS + LTRA
- SAB2A + ICS + LAB2A +- LTRA
- increase ICS dose
what does
SABA
LABA
SAMA
LAMA
stand for - asthma medications
- SABA is salbutamol
- LABA is Salmeterol (long acting bronchodilator)
- SAMA is Ipratropium bromide (short acting muscarinic antagonist)
- LAMA is Tiotropium bromide
What needs to be given in asthma exacerbations
O2
ICS (inhaled corticosteroids - Hydrocortisone)
IV MgSO4 (bronchodilation)
IV theophylline
PLUS
BIPAP/CPAP and antibiotics if an infection is present
what is a cancer of the pleura called
A mesothelioma
what are types of cancer of the bronchial parenchyma
Small cell
Non small cell
What are the types of non small cell lung cancer
Squamous cell
Adenocarcinoma
Carcinoid
Large cell
what is a mesothelioma
A malignancy of the pleura
What are causes of a mesothelioma
Asbestos
Who typically presents with mesothelioma
Males between 40-70
what are the symptoms of mesothelioma
Cancer symptoms - wt loss, TATT, night pain
Lung symptoms - SOB, persistent cough, pleuritic chest pain, hoarse voice, bone pain
why do you get bone pain in lung cancer (mesothelioma)
Sign of bone metastasis
why might you get horse voice with mesothelioma - lung cancer
as the tumour may press on nearby structures such as the recurrent laryngeal nerve causing hoarse voice
how do you diagnose mesothelioma
chest X ray and CT - imaging is first line
looks for cancer antigen CA-125
Biopsy - diagnostic
what is diagnostic in mesothelioma
performing a biopsy of the pleura
how do you treat mesothelioma
Very aggressive tumour so its normally palliative
if found early - surgery and chemo/radio therapy
what is a primary malignancy of lung parenchyma
Bronchial carcinoma
what are the two types of bronchial cell carcinoma
Small cell
Non small cell
what are risk factors of bronchial carcinoma
Smoking
Asbestos
Coal
Ionising radiation
lung disease present
what percentage of bronchial carcinoma is small cell lung cancer
15%
who gets small cell lung cancer
exclusively smokers
what is associated with small cell lung cancer
Paraneoplastic syndromes
what can small cell lung cancers produce
Ectopic ACTH - cushings
Ectopic - ADH - SIADH
Lambert eaton syndrome
what is the pathology of a small cell lung cancer
it is very fast growing with early metastasis
causing central lung lesions
what is a BALT lymphoma
a non hodgkin lymphoma originating in the bronchi
what percentage of non small cell cancers are squamous cell
25%
who does squamous cell lung cancer affect the most
mostly smokers
What is the pathophysiology of squamous cell lung cancer
it arises from lung epithelium and it affects the central lung, causes lesions with central necrosis. They may also secrete PTHrP causing hypercalcaemia
what is hypertrophic pulmonary osteoarthropathy
It is newly associated with NSCLC
it is a paraneoplastic syndrome associated with squamous cell carcinoma and causes clubbing, arthritis and pariostitis
what is the pathology of squamous cell lung cancer
It has mostly local spread with late metastasis
what percentage of non small cell lung cancers are adenocarcinoma
40%
who does adenocarcinoma of the lung affect
Commonly in those with asbestos exposure
Smokers
what cell type does adenocarcinoma of the lung arise from
Mucus secreting glandular epithelium
What part of the lung does adenocarcinoma affect
the peripheral lung
where are mets commonly found in adenocarcinoma of the lung
Bone
Brain
Adrenals
Lymph nodes
Liver
what is a carcinoid tumour
it is a neuroendocrine tumour (secretes SEROTONIN) which can appear in the lungs
symptoms only appear when liver mets are present
what genetic are carcinoid tumours associated with
MEN1 mutation and neurofibromatosis 1
what are general symptoms of lung cancers
Chest pain
cough
haemoptysis
cancer symptoms
signs of mets
how do you diagnose lung cancer
imaging - CXR CT
diagnostic - bronchoscopy and biopsy
MRI - staging, TNM
what is the biggest cause of secondary hypertrophic osteoarthritis
Adenocarcinoma
what is the triad seen in secondary hypertrophic osteoarthritis
Clubbing
arthritis
Long bone swelling
how do you treat small cell lung cancer
More aggressive
if caught early consider chemo/radiotherapy
if metastasised palliative care
how do you treat non small lung cancer
if caught early - surgical excision
if metastasised - chemo +/- radiotherapy
can also give mAb therapy such as cetuximab which is against epidermal growth factor
are primary or secondary lung tumours more common
Secondary tumours
Why are secondary tumours more common than primary ones
Lungs oxygenate 100% of the blood and therefore all the blood comes to the lungs, increasing the chance of mets risk
What cancers commonly metastasise to the lungs
Breast
Kidney
Bowel
Bladder
what is a pancoast tumour
It is a tumour in the lung apex which metastasised to the necks sympathetic plexus which causes horners syndrome
what is Horners syndrome
when there is ptosis, myosis and anhidrosis
- droopy eyelids
- contraction of pupil
- lack of sweat
what is a pulmonary embolism
It is when pulmonary artery circulation is blocked by a blood clot, usually an embolism of a DVT
what is a pulmonary embolism
It is when pulmonary artery circulation is blocked by a blood clot, usually an embolism of a DVT
what are risk factors for pulmonary embolism
Anything affecting virchows triad
immobility
post surgery
pregnancy
obesity
malignancy
Factor V leiden
antiphospholipid syndrome
smoking
hypertension
trauma
catheters
what is Virchows triad
implicates three contributing factors in the formation of thrombosis: venous stasis, vascular injury, and hypercoagulability
what is the pathophysiology of a pulmonary embolism
- DVT embolises and enters right heart
- moves to the lungs and occludes a small pulmonary vessel
- this causes reactive bronchoconstriction and dyspnoea
- embolus increases pulmonary pressure leading to hypertension
- hypertension leads to strain, and to cor pulmonale and right heart failure
what are symptoms of pulmonary embolism
Sudden onset shortness of breath
chest pain (pleuritic)
swollen calf (DVT)
Haemoptysis
increased jugular venous pressure
tachycardia and dyspnoea
what are signs of right sided heart failure
hypotensive
tachycardic
peripheral oedema
What is the wells score
Wells’ Criteria for Pulmonary Embolism objectifies risk of pulmonary embolism
what criteria are looked at in the Wells score
DVT
PE most likely differential diagnosis
HR less than 100
malignancy
haemoptysis
how do you diagnose pulmonary embolism
Well score - less than 4 PE unlikely, over 4 PE likely
D-Dimer
Gold standard CTPA
ECG
CXR
what is seen when testing D-dimer in a pulmonary embolism
if the D dimer is less than 500 then PE is unlikely if its over then PE is more likely
what is seen on ECG in someone with pulmonary embolism
S1Q3T3 - S waves deep in lead I, Q waves in lead III, T waves inverted in lead III
RBBB v1-3 - RSR pattern due to right axis deviation
sinus tachycardia
how do you treat pulmonary embolism if the patient is hemodynamically stable
Anticoagulants
1st line = DOAC: rivaroxaban, apixaban
If doacs contraindicated
1st line = low molecular weight heparin
2nd line = warfarin
how do you treat pulmonary embolism if the patient is haemodynamically unstable
Thrombolysis - alteplase
Catheter embolectomy
what can be given as prophylaxis in pulmonary embolism
compression stockings
regular walking
sc low molecular weight heparin
what is pneumonia
it is fluid exudation into the alveoli due to inflammation from infection
- typically bacterial
what is CAP
community acquired pneumonia
- appears less than 48 hours after admission
what are the most common causes CAP
S. pneumoniae
H. influenzae
Mycoplasmodium pneumoniae
what other bacteria can cause CAP
S. aureus
Legionella
Moraxella
chlamydia pneumoniae
what are viral causes of pneumonia
H. flu
CMV
what are fungal causes of pneumonia
P. Jirarechi
what is HAP
hospital acquired pneumonia
appears over 48 hours after admission
what bacteria cause HAP
P. aeruginosa
E. coli
Klebsiella
MRSA
how do people catch pneumonia
through inhalation of pathogens
aspiration
what are risk factors for pneumonia
Immunocompromised
IV drug users
pre-existing respiratory disease
Extremes of life
what is the pathophysiology of typical pneumonia
Bacteria invades and exudate forms inside the alveoli lumen
sputum on coughing
what is the pathophysiology of atypical pneumonia
The bacteria invades and exudate forms in the interstitium of the alveoli
dry cough
what are symptoms of pneumonia
Productive cough with rusty coloured sputum
Pyrexic
pleuritic chest pain
tachypnoea
dyspnoea
confusion in the elderly
what is seen on chest X ray in pneumonia
pneumonic lesions = fluid filled alveoli
what bacteria causes multilobular pneumonia
S. pneumoniae
S. aureus
legionella
What bacteria causes multiple abscesses in pneumonia
S. aureus
what bacteria affects the upper lobes in pneumonia
Klebsiella (exclude TB first)
how do you diagnose pneumonia
1st line diagnostic - chest X ray
sputum sample and culture
CURB65 for assessing severity in CAP
what is CURB65 when assessing CAP severity
Confusion
Urea nitrogen >7mmol/L
Respiratory rate > 30
Blood pressure <90/60 mmHg
65 + years old
how is the CURB65 score used when treating pneumonia
the score is out of 5
1 = Outpatient, oral antibiotics and discharge
2 = Consider short hospital stay and Abx
3 and over = hospital ICU, IV antibiotics
how do you treat pneumonia
Oxygen
antibiotics
analgesia
What antibiotics are used to treat CAP
Amoxicillin if CURB is 0-2
Co-amoxiclav and clarithromycin if CURB 3-5
what pneumonia causing disease is notifiable to PHE
Legionella
What medication does legionella causing pneumonia require
Clarithromycin is first line
what is aspiration pneumonia
It is seen in patients with a stroke, bulbar palsy and myasthenia gravis
- aspiration of gastric contents into the lungs
what is tuberculosis
a granulomatous caseating disease caused by mycobacteria
what are the four mycobacteria species known as the mycobacterium tuberculosis complex
M. tuberculosis
M. africanum
M. Microtis
M. Bavis
Where is M. Bavis found
in unpasturised milk
where is tuberculosis common
South asia - China, India and Pakistan
Subsaharan africa
how many people worldwide have TB
1.7 billion people
How it tuberculosis spread
airborne pathogen
what are risk factors for tuberculosis
country and travel associated
immunocompromised
Homeless/crowded housing
IV drug users
smoking and alcohol
increased age
what are the features of MTC (mycobacterium tuberculosis complex)
Non motile and non spore forming
Mycotic acid capsule - acid fast staining
resistant to phagolysosome killing
slow growing (15-20hr)
what is the pathophysiology of tuberculosis
- TB phagocytosed but isnt killed and forms a granuloma
- T cells are recruited and the central region of the granuloma undergoes caseating necrosis
- have primary Ghon focus formation in the upper parts of the lung
- Ghon focus spreads to lymph nodes close by
- this forms a ghon complex
- if infection spreads systemically its known as Miliary TB
What is TB known as if it spreads systemically
Miliary TB
In most how does TB survive
it survives within the granulomas and is known as latent TB
what causes latent TB to reactivate
in immunosuppressed patients it may reactivate
what are symptoms of TB
Characteristic = night sweats and weight loss
pyrexia
chest pain
if extrapulmonary can have meningitis fever, skin changes, TB pericarditis symptoms and joint pain
how do you diagnose TB
Mantoux skin test - latent or active
Sputum cultures - acid fast test
Biopsy
Chest X ray
how do you treat Tuberculosis
RI2PE6
Rifampicin - 2 months
Isoniazid - 2 months
Pyrimidine - 6 months
Erythromycin - 6 months
what is a side effect of rifampicin
Bloody/red urine and tears
What is a side effect of Isoniazid
peripheral neuropathy - tingling hands and feet
What is a side effects of pyrimidine
Hepatitis
what is a side effect of ethambutol
optic neuritis - eye problems
what are types of interstitial lung diseases
Granulomatous - sarcoidosis
Inhalational - hypersensitivity pneumonitis
Idiopathic pneumonias - pulmonary fibrosis
Conn tissue - scleroderma
Drug induced - Amiodarone
Other - goodpastures, vasculitis
what is the most common interstitial lung disease
pulmonary fibrosis
what demographic is pulmonary fibrosis most commonly seen in
Older men (60+) who smoke
What are risk factors for developing pulmonary fibrosis
smoking
occupational - dust
drugs - methotrexate
viruses - EBV, CMV
what drug can cause pulmonary fibrosis
methotrexate
what viruses can cause pulmonary fibrosis
EBV and CMV
what is the pathology of pulmonary fibrosis
progressive scarring of the lungs eventually leads to a type 1 respiratory failure
what are symptoms of pulmonary fibrosis
Exertional dyspnoea
dry unproductive cough
how do you diagnose pulmonary fibrosis
spirometry = restriction
FV1:FVC is over 0.7
FVC is low (less than 0.8)
Gold standard = High resolution CT
what is seen on chest CT in someone with pulmonary fibrosis
Ground glass lungs
traction bronchiectasis
how do you treat pulmonary fibrosis
smoking cessation and vaccines
Pirfenidone
Nintendanib
Surgery - lung transplant
what is pneumoconiosis
it is an occupationally acquired form of interstitial lung disease
what are the two types of pneumoconiosis
Silicosis
Asbestosis
what is silicosis
this is inhalation of silicon dioxide causing eggshell calcification and hilar lymph nodes
What is asbestosis
This is the inhalation of asbestos which affects the pleura and can cause mesothelioma
what is sarcoidosis
this is an idiopathic granulomatous disease
what demographic is sarcoidosis most common in
women
20-40yrs
Afro-Caribbean
what are the symptoms of sarcoidosis
Fever
fatigue
dry cough
dyspnoea
eye lesions
lupus pemio
what is Lefgrens syndrome
it is a subset of sarcoidosis
what triad is seen in Lefgrens syndrome
Bilateral hilar infiltration
Erythema nodosum
Acute polyarthritis
how do you diagnose sarcoidosis
chest X ray - staging 1-4
Diagnostic - biopsy
bloods -increased serum calcium and ACE
what is seen on a chest X ray in sarcoidosis
Bilateral Hilar adenopathy
pulmonary infiltrate
what is seen on biopsy in sarcoidosis
Non caseating granulomas
how do you treat sarcoidosis
Early stages = Self resolving
Symptomatic = Corticosteroids
what is hypersensitivity pneumonitis
it is a T3 hypersensitivity: immune Ab-Ag deposition at the lung tissues and causes immune hyperresponsiveness
what are risk factors for hypersensitivity pneumonitis
occupation - farmer
bird keeping
what are types of hypersensitivity pneumonitis
Farmer’s lung - mouldy hay (MC)
pigeon fanciers lung - anon protein in bird poo
malt workers lung
cheeseworkers lung
humidifier fever
how do you treat hypersensitivity pneumonitis
remove the allergen
what is goodpastrues syndrome
it is a T2 autoimmune hypersensitivity response
what is the pathology of Goodpastrues syndrome
There are autoantibodies (AntiGBM) which attack the lungs and kidneys leading to lung fibrosis and glomerulonephritis
how do you diagnose Goodpastures disease
lung and kidney biopsy
serology - anti GBM positive
what is seen on the lung and kidney biopsy in Goodpastures syndrome
damage and Ig deposition
how do you treat goodpastures syndrome
Supportive
corticosteroids
plasma exchange - get rid of Anti-GBM
what is Wegners granulomatosis
it is a granulomatosis vasculitis affecting small and medium vessels typically causing BNT, lung and kidney symptoms
what is Wegners granulomatosis associated with
c-ANCA associated vasculitis
what are symptoms of Wegners granulomatosis
Saddle shapes nose
Ear infection
diffuse alveolar haemorrhage
haemoptysis
granulonephtitis
haematuria
how do you diagnose Wegners granulomatosis
ANCA positive
how do you treat Wegners granulomatosis
Corticosteroids
immunosuppression - rituximab
what is bronchiectasis
it is the permanent dilation of the bronchioles
and excessive mucus within them
what are the symptoms of bronchiectasis
productive cough with lots of sputum and dyspnoea
what are risk factors for developing bronchiectasis
MC - post infection
HIV
Cystic fibrosis
ABPA
what is the pathology of bronchiectasis
there is irreversible dilation, loss of cilia and mucus hypersecretion which increases risk of infection as there is a reduction in mucociliary clearance
how do you diagnose Bronchiectasis
Imaging - chest X ray
Gold - HRCT
spirometry - obstructive FEV1:FVC <0.7
sputum culture
what is seen on HRCT in bronchiectasis
Dilated thickened bronchi
cysts at the end of bronchi
what organisms may be found in the lungs in Bronchiectasis
H. Influenzae
S. Pneumoniae
P. Aeruginosa
how do you treat bronchiectasis
non curative
conservative = chest physio and stop smoking
Bronchodilators
antibiotics if infection is present
what is cystic fibrosis
an autosomal recessive mutation on chromosome 7 in the gene that encodes the CFTR protein
what are risk factors for cystic fibrosis
family history
caucasians
what is the pathology behind cystic fibrosis
There is a defective CFTR gene which prevents CL-, Na+ and H2O secretion making mucus secretions thicker with more sodium and chloride retention
what is the normal function of the CFTR protein
secretion of Cl- actively and Na+ passively (+H2O) into ductal secretions making them thin and watery
what affect does CFTR gene mutation have on the lungs
there is impaired mucociliary clearance as the mucus is extra thick which causes an increase in stagnation and increased infection risk
it causes difficulty breathing and increases risk of bronchiectasis
what are the respiratory symptoms of cystic fibrosis
Thick and sticky sputum cough
recurrent infection
bronchoiectasis
what are neonate symptoms in cystic fibrosis
Meconium ileus - earliest stool is too thick to pass through bowel and causes an obstruction
failure to thrive
what are GIT symptoms of cystic fibrosis
thick secretions
pancreatic insufficiency
bowel obstruction
what may males with cystic fibrosis experience
atrophy of the vas deferens and epididymis
how do you diagnose cystic fibrosis
sweat test - high sodium and chloride
Fecal elastase - negative in CF
family history
genetic testing
how do you treat cystic fibrosis
non curative
conservative - chest physio and stop smoking
drugs - antimucolytics, bronchodilators, pancreatic enzyme replacement, fast soluble vitamin supplements
what are common infections in CF patients
S. aureus
H. influenzae
P. Aeruginosa
(same as in bronchiectasis)
what is pleural effusion
when there is excess fluid accumulation between the visceral and parietal pleural layers
what are the two types of pleural effusion
Transudative
Exudative
what is transudative pleural effusion
it is when there is low protein (<25g/L)
what causes transudative pleural effusion
an increase in hydrostatic pressure or reduced oncotic pressure - transparent fluid
- congestive heart failure
- liver cirrhosis
- nephrotic syndrome
what is exudative pleural effusion
when there is high protein (>35 g/L)
what causes exudative pleural effusion
inflammation causing a high vascular permeability - cloudy
- cancer
- TB
-pneumonia
what are symptoms of pleural effusion
Generic dyspnoea
pleuritic chest pain
cough
decreased breathy sounds
dull percussion on ipsilateral side
what is lights criteria used for
In pleural effusion when the excess fluid protein is between 25-35g/L
what would be hyperresonant on lung percussion
pneumothorax
How do you diagnose pleural effusion
Chest X-ray
Thoracocentesis - sample of pleural fluid
what is seen on a chest X ray in pleural effusion
decreased costophrenic angles
excess fluid appears white
tracheal indentation may be present
what is pleural fluid tested for in pleural effusion
pH
lactate
White cell count
microscopy
transudate or exudate
how do you treat pleural effusion
chest drain
if recurrent then pleurodesis
what is pleurodesis
surgical joining of the pleural layers
what is a pneumothorax
it is excess air accumulation in the pleural space causing ipsilateral collapse
who typically presents with pneumothorax
tall thin males
connective tissue disorders such as marfans
smokers
what are the two types of pneumothorax
primary - spontaneous
secondary - trauma/pathology
what is the pathology of pneumothorax
the pleural space is normally a vacuum
a breach in the pleura causes an abnormal space between the pleura and the airways introducing air into the pleural space = pneumothorax
what are symptoms of a pneumothorax
shortness of breath
one sided sharp pleuritic pain
decreased breathing sounds
hyperresonant percussion unilaterally
how do you diagnose a pneumothorax
Chest X ray - excess air appears black and there is tracheal deviation to the otherside
CT is more sensitive to small pneumothoraxes
how do you treat a pneumothorax
small = self healing
larger = needle decompression (suck air out) or a chest drain
Surgical if recurrent = pleurodosis
what is a simple pneumothorax
it is a non medical emergency when there is little tracheal deviation and air can flow in and out of the valve between the alveoli and the pleura
- doesnt/unlikely to worsen with every breath
what is a tension pneumothorax
medical emergency with contralateral tracheal deviation.
there is a one way valve between the alveoli and pleura where air can flow in but not out meaning it worsens with every breath
how do you treat a tension pneumothorax
insert a large bore cannula into the second intercostal space at the midclavicular line
needle decompress and then chest drain
what is cor pulmonale
it is right circulation (pulmonary hypertension) changes which directly causes right heart failure
what is pulmonary hypertension
a resting pulse pressure of over 25mmHg, measured with right heart catheterisation
what are causes of pulmonary hypertension
pre-capillary
capillary and lung
post capillary
chronic hypoxemia
what are pre capillary causes of pulmonary hypertension
pulmonary emboli
primary pulmonary hypertension
what are capillary and lung causes of pulmonary hypertension
COPD
asthma
what are post capillary causes of pulmonary hypertension
LV failure
what are chronic hypoxemia causes of pulmonary hypertension
COPD
altitude
what is the pathophysiology of pulmonary hypertension
- due to pulmonary hypertension there is reactive pulmonary vasoconstriction
- this increases pulmonary vascular resistance and pressure increasing endothelial damage
- this causes right ventricular hypertension and failure
what are the symptoms of pulmonary hypertension
usually on exertional dyspnoea and fatigue
then RHF signs
- increased jugular venous pressure
- peripheral oedema
- V waves prominent on JVP
- Louder S2 than normal
how do you diagnose pulmonary hypertension
Chest X ray
ECG
ECHO - right ventricular hypertension
GS = right heart catheter to measure pressure
what is seen on a chest X ray in pulmonary hypertension
signs of right ventricular hypertension - enlarged proximal pula
what is seen on an ECG in pulmonary hypertension
RA dilation - peaked P waved of over 2.5mm
how do you treat pulmonary hypertension
phosphodiesterase S inhibitor (sildenafil)
CCB (amlodipine)
Endothelin 1 antagonist/prostaglandin analogue
diuretics for oedema
what is pharyngitis
inflamed pharynx plus of minus exudate
what are viral causes of pharyngitis
EBV
Adenovirus
what are bacterial causes of pharyngitis
Group A beta haemolytic strep - S. pyogenes
what are symptoms of pharyngitis
sore throat
fever
Viral - cough and nasal congestion
Bacterial - Exudate
what is important to rule out if someone has bacterial pharyngitis
Rheumatic fever
what is rheumatic fever
a systemic inflammatory disease typically 2-4 weeks post group A strep infection
how would you treat bacterial pharyngitis
amoxicillin
what is sinusitis
it is inflamed mucosa of the nasal cavity and nasal sinuses
what are causes of sinusitis
it is mostly viral (less then 10 days non purulent discharge)
Sometimes bacterial (over 10 days, purulent)
what are causes of bacterial sinusitis
S. pneumo
H. influenzae
how do you treat bacterial sinusitis
Amoxicillin
what is Otitis media
it is an inflamed middle ear, typically in children
what can cause otitis media
bacterial - streptococcus
Viral
how do you diagnose otitis media
an otoscopy shows inflamed erythematous tympanic membrane
what can sinusitis and otitis media be linked to
meningitis contagious spread - direct
what is epiglottitis
it is inflammation of the epiglottis - mostly in children
what is the most common cause of epiglottitis
H. influenzae
What are symptoms of epiglottitis
tripoding - leant forward, mouth open and tongue out to maximise air in
sore throat
shortness of breath
how do you diagnose epiglottitis
laryngoscopy is gold standard
lateral radiograph - thumb print sign
what is whooping cough
a chronic cough caused by bordella pertussis mainly seen in children
what type of bacterial is Bordella pertussis
a gram negative bacillus
what virulence factors does bordella have to increase infection risk
- Haemagglutinin and fibroae adhere to the URT
- Adenylate cyclase toxin inhibits phagocyte chemotaxis
- Pertussis toxin inhibits alveolar macrophages
what is croup/laryngobronchitis
an occasional complication of an upper respiratory tract infection particularly from parainfluenza and measles in children
what are the symptoms of croup/laryngobronchitis
hoarse voice
barking cough
stridor - high pitched wheeze when inhaling
how do you treat Croup/Laryngobronchitis
single dose of dexamethosone
what are risk factors for asthma
History of atopy
Low birth weight
Not breastfed
Exposure to allergens
what investigations are done for asthma
FEV1 - reduced
FCV - normal
FEV1/FVC is less than 0.7
FeNO3 - adults over 40pbb and children over 35
what can be used for acute asthma management
- oxygen
- salbutamol nebulisers
- ipratropium bromide nebulisers
- hydrocortisone IV or oral prednisolone
- IV magnesium sulphate
- Aminophylline or IV salbutamol
in asthma what if pCO2 is normal
this is a bad sign as it means that the patient is tiring
what is type 1 respiratory failure
It is caused by fibrosis where the lung fails to fill properly
Low PaO2 and PaCO2 is normal or low
how do you treat type 1 respiratory failure
Continuous positive airway pressure
What is type 2 respiratory failure
caused by obstruction where the lung fails to remove CO2 properly
PaO2 is low and PaCO2 is high
what diseases show type 2 respiratory failure
COPD
Asthma
how do you treat type 2 respiratory failure
Bi positive airway pressure
what is seen on chest X ray in patients with COPD
hyperinflation
Bullae - fluid filled sac or region
flat hemidiaphragm
Exclude malignancy!
when should you consider long term oxygen in COPD
when the FEV1 is less than 30% predicted
cyanosis
polycythaemia
peripheral oedema
raised JVP
O2 less than or equal to 92% on room air
how do you manage a primary pneumothorax
if its less than 2cm then discharge
aspiration
chest drain
how do you manage a secondary pneumothorax
- <1cm: O2 and admit
- 1-2cm: aspirate
- > 2cm: chest drain
how do you manage cystic fibrosis
Chest physio and postural drainage
high calorie, high fat diet
minimise contact with other infective patients
pancreatinc supplementation
what are causes of bronchiectasis
Post infection
CF
lung cancer
how do you manage bronchiectasis
Physical training
postural drainage
Prophylactic antibiotics
Surgery (localised disease)
what organism causes pneumonia in immunocompromised patients
Pneumocystis Jiroveci
what organisms can cause atypical pneumonia
Legionella pneumophila
mycoplasma pneumoniae
chlamydia psittaci
chlamydiopilia pneumoniae
coxiella burnetii
what pneumonia signs are heard on auscultation
Decreased air entry
wheezing
course crackles
bronchial breath sounds
increased vocal resonance
what would be seen on a chest X ray of someone with pneumonia
Localised or widespread consolidation, effusion, abscess and empyema
what would be seen on FBC on someone with pneumonia
Increased white cell count
increased urea
increased CRP
what is the definition of pharyngitis
Acute pharyngitis is characterised by the rapid onset of a sore throat and inflammation of the pharynx (with or without exudate)
what are common viral causes of pharyngitis
Rhinovirus
RSV
Adenovirus
Enterovirus
Influenza A and B
Parainfluenza
EBV
CMV
what are symptoms of pharyngitis
Sore throat - difficulty swallowing
Fever
Headache
Joint pain or muscle ache
Skin rashes
Swollen lymph nodes in the neck
what are viral specific symptoms of pharyngitis
runny nose
blocked nose
sneezing
cough
what are bacterial specific symptoms of pharyngitis
Fever
pharyngeal exudate
cervical lymphadenopathy
absence of cough and runny nose
what investigations are done for pharyngitis
Assess the likelihood of Strep A infection
Rapid antigen detection test
what is the treatment for viral pharyngitis
Normally self resolving
supportive care
what is the treatment for bacterial causing pharyngitis
Phenoxymethylpenicillin (or clarithromycin if penicillin allergic)
what is the aetiology of sinusitis
common infectious agents are
- streptococcus pneumoniae
- Haemophilus influenzae
- Rhinovirus
what is double sickening in sinusitis
when someone has a viral infection which progresses to a secondary bacterial infection
what are risk factors for sinusitis
Nasal pathology - septal deviation or nasal polyps
Recent local infection - dental extraction
Swimming or diving
Smoking
how does viral sinusitis present
symptoms usually last less than 10 days
- clear nasal discharge
- fever
- sore throat
How does bacterial sinusitis present
symptoms are over 10 days
- purulent nasal discharge
- nasal obstruction
- dental or facial pain
- headache
how do you treat sinusitis
symptom management with analgesia and intranasal decongestants
Nice - Internasal corticosteroids if symptoms last longer than 10 days
Abx not required but can be given in severe presentations - phenoxymethylpenicillin
what type of lung cancer has worse prognosis
Small cell lung cancer
what type of lung cancer is more common
Non small cell lung cancer - 80-85% of all cases
what is the epidemiology of lung cancer
it is the third most common cancer in the UK behind breast and prostate
what is the most common cancer cell type in non smokers
adenocarcinoma
what lung cancer is most strongly associated with cigarette smoking
Squamous cell carcinoma
what is more common, primary or secondary lung cancer
Secondary
what are the most common sites for lung cancer metastasis
Liver
Bone
Adrenal glands
Brain
what paraneoplastic changes can occur in lung cancer
increased PTH - hyperparathyroidism
Increased ADH - SIADH
increased ACTH - cushings syndrome
what are extrapulmonary manifestations of lung cancer
Recurrent laryngeal nerve palsy - hoarse voice
Superior vena cava obstruction - facial swelling, distended veins in neck and chest, Pembertons sign
Horners syndrome - ptosis, miosis, anhidrosis
what are symptoms of metastatic disease
Bone pain
Headache
Seizures
Neuro deficit
Abdominal pain
what is diagnostic for lung cancer
Percutaneous or bronchoscopic biopsy and histology
what is seen on a chest X ray in someone with lung cancer
Opacified lesion
Hilar enlargement
Pleural effusion (usually unilateral)
collapse
what type of pleural effusion is due to systemic causes
Transudative
what are causes for transudative pleural effusion
Congestive heart failure
Fluid overload
Hypoalbuminemia (cirrhosis, nephrotic syndrome)
what are causes for exudative pleural effusion
lung cancer
Pneumonia
TB
RA
what is seen if there is a large plural effusion
can have tracheal deviation away from the effusion
what are different treatment options for pleural effusion
dependent on the cause
fluid overload or congestive HF - diuretic
Infective - antibiotics
large effusions need aspiration or drainage
what are symptoms of pulmonary embolism
Acute onset shortness of breath
cough +/- hemoptysis
Pleuritic chest pain
What are signs of pulmonary embolism
DVT - unilateral leg swelling and tenderness
Hypoxia
tachycardia
increased respiratory rate
low grade fever
haemodynamic instability causing hypotension
what are the things looked at by the wells score
clinical signs and symptoms of DVT - 3 points
Alternative diagnosis less likely than PE - 3
Bed for 3+ days or major surgery - 1 point
Heart rater over 100bpm - 1.5 points
Immobilisation for over 3 weeks - 1.5
previous DVT -PE - 1.5 points
Haemoptysis - 1 point
Active cancer - 1 point
if someone is haemodynamically unstable how do you treat a pulmonary embolism
IV thrombolysis
Catheter - direct thrombolysis
Embolectomy - surgery
what do you give someone with suspected PE if their investigations are delayed
Start on interim therapeutic anticoagulation
What do you do if anticoagulation reoccurs or if treatment is unsuccessful
put in an IVC filter - An IVC filter is a small metal device that traps large clot fragments and prevents them from traveling through the vena cava vein to the heart and lungs
what is the pathophysiology of COPD
There is chronic inflammation affecting the central and peripheral airways, lunch parenchyma and the alveoli
there is repeated injury and repair leading to structural and physiological changes
narrowing and remodeling of airways, increased goblet cells, enlargement of mucus secreting glands, alveolar loss and pulmonary hypertension
How is breathlessness categorised according to the medial research council
0 = no breathlessness except with hard exercise
1 = SOB when hurrying or walking up hill
2 = walks slower than people same age or stops for breath when walking the same pace
3 = Stops for breath when walking after 100m
4 = too breathless to leave the house
What are differentials for COPD
Asthma
Congestive heart failure
Bronchiectasis
TB
Bronchiolitis
Upper airway dysfunction
Chronic sinusitis/postnasal drip
GORD
CEi induced cough
Lung cancer
what are possible complications of COPD
Cor pulmonale
Lung cancer
Recurrent pneumonia
Depression
Pneumothorax
Respiratory failure
Anaemia
Polycythaemia
what is the definition of chronic bronchitis
bronchitis over 3 months a year for over 2 years
what is bronchitis
it is inflammation of the bronchi
what does chronic bronchitis lead to
leads to narrowing of the airways due to tissue swelling and excess mucus production
what is the pathophysiology of chronic bronchitis
Enlargement of the mucus secreting glands
Increased in number of goblet cells
After inflammation there is fibrosis leading to thickening of wall and reduced lumen size and a decreased FEV1
what are the main immune cells involved in chronic bronchitis
Neutrophils
CD8 T cells
what are features of acute bronchitis
Cough - chesty
Often productive - clear, yellow or green
lasts 2 weeks
Fever
how is acute bronchitis managed
it is self limiting
what is the pathophysiology of emphysema
Loss of elasticity of the alveoli
Inflammation and scarring reduces size of lumen
Mucus hypersecretion reduces size of lumen
what are differential diagnosis for asthma
CF
Chronic rhinosinusitis
Trachemolacia
Vascular ring
Foreign body aspiration
Vocal cord dysfunction
Alpha-1-antitrypsin deficiency
COPD
Bronchiectasis
PE
Congestive Heart Failure
Common Variable Immunodeficiency
what are complications of asthma
Airway remodelling
what lung cancer commonly invades the mediastinal lymph nodes and the pleura
adenocarcinoma
what lung cancer is well differentiated and matastisises early
Large cell carcinomas of the lung
what lung cancer arises from endocrine cells (Kulchintsky cells)
Small cell carcinoma of the lung
what are complications of pulmonary embolism
Pulmonary infarction
Cardiac arrest/death
Chronic thromboemolic pulmonary hypertension
Recurrent venous thromboembolic event
what are differential diagnosis for TB
COVID-19
Community-acquired pneumonia
Lung cancer
Non-tuberculosis mycobacterium
Fungal infection
Sarcoidosis
what are risk factors for pneumonia
Strep pneumonia infection (allows viral infection with influenza or parainfluenza)
Hospitalisation
Cigarette smoking
Alcohol exces
Bronchiectasis
Bronchial obstruction
Immunosuppression
IV drug use
Dysphagia
what are complications of pneumonia
Respiratory failure
Hypotension
Pleural effusion
Empyema
Lobar collapse
Thromboembolism
Pneumothorax
Lung abscess
Septicaemia
ARDS
what are causes of Otitis media
Virus
Step. Pneumoniae
Strep. Aureus
H. Influenzae
what is the clinical presentation of epiglottitis
Acute onset fever
sore throat
respiratory distress
tachycardia
hypotension
what is the clinical presentation of otitis media
Fever discharge
ear ache
what is the clinical presentation of sunisutis
non resolving
biphasic cold pattern
pain
purulent discharge
anosmia
what are the clinical presentations of pharyngitis
Inflammation
exudate
fever
tender cervical lymph nodes
how id epiglottitis managed
Abs - amoxicillin, ampicillin, erythromycin
how is otitis media managed
Penicillins
macrolides
how is sinusitis managed
Amoxicillin
what are complications of pharyngitis
Scarlet fever
rheumatic fever
post strep glomerulonephritis
what are complications of pulmonary fibrosis
Pulmonary hypertension
Lung cancer
GORD
Pulmonary infection
Pneumothorax
PE
DVT
ACS
what is the pathology of idiopathic pulmonary fibrosis
Pro-inflammatory response is triggered
Influx of immune cells
Dysregulation of normal tissue repair process
Fibroblastic and myofibroblastic activity persists
there is alveolar destruction, infiltration into interstitial space and architectural distortion of lung parenchyma
what is the clinical presentation of idiopathic pulmonary fibrosis
Dyspnoea
Cough
Crackles
Weight loss
Fatigue
Malaise
Clubbing
what parts of the body does sarcoidosis commonly affect
Lung, skin and eyes
what is the pathophysiology of sarcoidosis
There is non caseating granuloma formation with multi nucleated giant cells in the centre
CD4 lymphocytes are spread throughout with CD8 around periphery
CD4 and cytokines promote and maintain the granulomas
what are differential diagnosis for sarcoidosis
TB
Histoplasmosis
Non small cell lung cancer
Lymphoma
Berylliosis
Hypersensitive pneumonitis
what is bronchiectasis normally a consequence of
Recurrent and or severe infections secondary to an underlying condition
what are causes of bronchiectasis
Post - infectious
Immunodeficiency
Genetic
Aspiration/inhalation injury
Inflammatory bowel disease
COPD and asthma
Idiopathic
what is the clinical presentation of bronchiectasis
Cough
Sputum production
Crackles, high-pitched
inspiration and rhonchi
Dyspnoea
Fever
Fatigue
Haemoptysis
Rhinosinusitis
Weight loss
Wheezing
what are differential diagnosis for bronchiectasis
COPD
asthma
pneumonia
chronic sinusitis
what are complications of bronchiectasis
Massive haemoptysis
respiratory failure
cor pulmonale
ischaemic stroke
why does CF lead to pancreas dysfunction
thick sticky secretions leads to blockage of the exocrine ducts
early activation of pancreatic enzymes
eventual autodigestion of the exocrine pancreas
how does CF affect the intestine
bulky stool can lead to intestinal blockage
what is differential diagnosis for cystic fibrosis
primary ciliary dyskinesia
primary immunodeficiency
Asthma
GORD
chronic aspiration
failure to thrive
coeliac disease
protein losing enteropathy
what inhaler is used in asthma
short acting inhaler - salbutamol
what are risk factors of pleural effusion
congestive heart failure
pneumonia
malignancy
what are differential diagnosis for pleural effusion
Pleural thickening
pulmonary collapse and consolidation
elevated hemidiaphragm
pleural tumours/extrapleural fat
covid -19
what are complications of pleural effusion
Atelectasis or lobar collapse
re-expansion pulmonary oedema
pleural fibrosis
pseudochylothorax
trapped lung
what are causes of pneumothorax
chest injury
lung disease
ruptured air blisters
mechanical ventilation
what are risk factors for pneumothorax
smoking
genetics
lung disease
mechanical ventilation
previous pneumothorax
what are differential diagnosis for pneumothorax
Asthma
COPD
PE
Myocardial ischaemia
Pleural effusion
Bronchopleural fistula
Fibrosing lung disease
Oesophageal perforation
Giant bullae
what are possible complications for a pneumothorax
Re-expansion pulmonary oedema
what are group 1 causes of pulmonary hypertension
primary pulmonary hypertension or connective tissue disease
what are group 2 causes of pulmonary hypertension
left heart failure
what are group 3 causes for pulmonary hypertension
chronic lung disease
what are group 4 causes of pulmonary hypertension
pulmonary vascular disease - embolism
what are group 5 causes of pulmonary hypertension
miscellaneous causes
- sarcoidosis
- glycogen storage disease
- haematological disorders
what are complications of pulmonary hypertension
respiratory failure
heart failure
arrhythmias
what are risk factors for hypersensitivity pneumonitis
smoking
viral infection
exposure to antigens
nitrofurantoin, methotrexate, roxithromycin, rituximab
herbal supplements
what are signs and symptoms of hypersensitivity pneumonitis
Dysponea
Cough (+- productive)
Fevers/chills
Malaise
Weight loss/anorexia
Bibasilar rales
Diffuse rales
Clubbing
how do you diagnose hypersensitivity pneumonitis
Immune response to causative antigen
FBC
CXR - fibrosis
Pulmonary function test
what is the treatment for hypersensitivity pneumonitis
avoidance of causative antigen
corticosteroid - prednisolone
what is coal worker pneumoconiosis
accumulation of dust in the lungs and the reaction of the tissue to it being there
what type of asbestos is most fibrogenic
blue - crocidolite
what is the pathophysiology of silicosis
silica is particularly toxic to alveolar macrophages and initiates fibrogenesis
what is the pathophysiology of asbestosis
it has distinct cellular infiltrate and extracellular matrix deposition distal to the terminal bronchiole
what is the clinical presentation of progressive massive fibrosis
black sputum
effort dyspnoea
fibrosis
emphysema
what is the clinical manifestation of silicosis
progressive dyspnoea
what is the clinical manifestation of asbestosis
dyspnoea
finger clubbing
bilateral basal end inspiratory crackles
pleural plaques
what is the pathophysiology of goodpastures disease
autoimmunity directed against the alpha-3 chain of type IV collagen
what are risk factors for goodpastures disease
HLA DRB1 or DR4
what are symptoms of Goodpastures disease
Reduced urine output
Haemoptysis
Oedema
Male sex
20-30; 60-70yo
SOB
Cough
Fever
Nausea
Crackles on lung examination
what are complications of Goodpastures disease
Pulmonary haemorrhage
CKD
what is the classic triad seen with Granulomatosis with polyangiitis (Wegeners granulomatosis)
upper and lower respiratory tract involvement
pauci-immune glomerulonephritis
What is the pathophysiology of granulomatosis with polyangiitis?
Granulomatous inflammation and vasculitis are the histopathological hallmarks of the disease
Necrotising inflammation is typical
What are the risk factors for granulomatosis with polyangiitis?
Genetic predisposition
Infection
Environmental exposures - Silica and other occupational exposures have been proposed as triggers
why do you get bone pain in lung cancer (mesothelioma)
Sign of bone metastasis
why do you get bone pain in lung cancer (mesothelioma)
Sign of bone metastasis
