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Respiratory > Respiratory 1 > Flashcards

Respiratory 1 Flashcards

1
Q

what is cor pulmonale?

A

enlargement and failure of right side of the heart due to disease of lungs/pulmonary blood vessels - leads to oedema and raised JVP

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2
Q

describe what is happening in the lungs of a patient with extrinsic allergic alveolitis (hypersensitivity pneumonitis)

A

inhalation of allergens provokes a hypersensitivity reaction, with complement activation, granuloma formation and obliterative bronchiolitis.

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3
Q

give 2 causes of EAA (hypersensitivity pneumonitis)

A 
Farmer's lung.
Bird-fancier's lung - proteins in bird droppings.
Malt-worker's lung.
Bagassosis/Sugar worker's lung.
humidifier fever.
Mushroom workers.
Cheese washer's lung.
Wine maker's lung.
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4
Q

give 3 clinical features of EAA seen after exposure to the allergen

A

fevers, rigors, myalgia, dry cough, dyspnoea, crackles (no wheeze)

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5
Q

give 3 chronic features of EAA

A

increasing dyspnoea, weight loss, exertional dyspnoea, type I respiratory failure, cor pulmonale

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6
Q

what would been seen on CXR of a patient with EAA?

A

fibrosis/mottling of upper lobes and honeycomb lung

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7
Q

list some investigations that might be performed on a patient with EAA

A

bloods - neutrophilia, raised ESR
CXR.
lung function tests (reversible restrictive).
broncheoalveolar lavage.

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8
Q

how would you treat EAA in an acute and a chronic situation?

A

acute - remove allergen, give O2 + oral prednisolone.

chronic - avoid exposure (facemask), long-term steroids.

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9
Q

list 3 occupational lung diseases

A 
EAA (e.g. Farmer's lung).
Coal worker's pneumonconiosis.
Silicosis. 
Asbestosis.
Byssinosis.
Berylliosis.
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10
Q

what causes the fibrosis seen in coal worker’s pneumoconiosis?

A

inhalation of coal dust particles - ingested by macrophages - these die and release their enzymes - fibrosis

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11
Q

what would a CXR show in coal worker’s pneumoconiosis?

A

round opacities in upper zone.

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12
Q

what causes progressive massive fibrosis? what are the features of this?

A

progression of coal worker’s pneumoconiosis.

progressive dyspnoea, fibrosis + eventual cor pulmonale.

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13
Q

give some examples of jobs at risk of silicosis

A

metal mining, stone quarrying, sand blasting, pottery/ceramic manufacture

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14
Q

what do investigations show in silicosis?

A

CXR - diffuse miliary/nodular pattern in upper and mid-zones + egg shell calcification of hilar nodes.
Spirometry - restrictive.

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15
Q

what disease are patients with silicosis at greater risk of?

A

TB

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16
Q

what are the clinical features of asbestosis?

A

progressive dyspnoea.

O/E - clubbing, fine end-inspiratory crackles, pleural plaques.

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17
Q

what two diseases are asbestosis patients at greater risk of?

A

bronchial adenocarcinoma and mesothelioma

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18
Q

in what industries might workers get byssinosis? and for berylliosis?

A

byssinosis - cotton mill workers.

berylliosis - beryllium-copper alloy used in aerospace industry, electronics, atomic reactors.

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19
Q

describe the pathogenesis of bronchiectasis

A

chronic infection of bronchi/bronchioles leads to inflamed, thickened and irreversibly damaged walls with permanent dilation.
mucociliary transport mechanism is impaired.

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20
Q

give 2 of the main organisms involved in bronchiectasis

A

H influenza, Strep pneumonia, Staph aureus, Pseudomonas aeruginosa

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21
Q

give 3 possible causes of bronchiectasis

A

congenital - CF.
post-infection - measles, pertussis, pneumonia, TB, HIV.
Other - bronchial obstruction (tumour, foreign body), allergic bronchopulmonary aspergillosis (ABPA), hypogammaglobulinaemia, rheumatoid arthritis, UC.

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22
Q

give 3 clinical features of bronchiectasis

A

persistent cough, copious purulent sputum, intermittent haemoptysis, finger clubbing, coarse inspiratory crepitations, wheeze

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23
Q

give 2 possible complications of bronchiectasis

A

pneumonia, pleural effusion, pneumothorax, haemoptysis, cerebral abscess, amyloidosis

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24
Q

name 3 investigations you would carry out in bronchiectasis and their results

A

*sputum culture.
*CT scan - shows the dilated airways.
CXR - cystic shadows, thickened bronchial walls.
spirometry - obstructive pattern.
broncoscopy - locate site of haemoptysis, exclude obstruction, obtain samples.

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25
Q

how would you manage a patient with bronchiectasis?

A

physiotherapy - postural drainage.
Abx - flucloxacillin for staph, amoxicillin for strep, tazocin for pseudomonas.
bronchodilators - salbutamol nebulisers.
Oral/inhaled corticosteroids.

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26
Q

what causes cystic fibrosis?

A

autosomal recessive mutation in the CF transmembrane conductase regulator gene on chromsome 7.
defective chloride secretion and increased sodium absorption over airway epithelium - produces very viscous and sticky mucous.

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27
Q

give 3 respiratory symptoms of CF

A

cough, wheeze, recurrent infections, bronchiectasis, pneumothorax, haemoptysis, respiratory failure, cor pulmonale

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28
Q

give 3 extrapulmonary features of CF

A

pancreatic insufficiency - DM, steatorrhoea.

intestinal obstruction, gallstones, cirrhosis, male infertility, osteoporosis, arthritis, vasculitis, sinusitis.

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29
Q

name 3 investigations you would carry out in CF and their results

A

sweat test - increased sodium and chloride secretion in sweat.
faecal elastase - screens for pancreatic dysfunction.
genetic screening for CF mutations.
CXR - hyperinflation, bronchiectasis.

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30
Q

how would CF be managed?

A 
physiotherapy.
Abx for exacerbations.
mucolytics - DNase (dornase alfa).
bronchodilators.
fat soluble vit supplements.
pancreatic enzyme replacement.
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31
Q

what is sarcoidosis? what genes is it associated with?

A

multisystem granulomatous disorder of unknown cause.

associated with HLA-DRB1 and DQB1 alleles.

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32
Q

what is seen on transbronchial biopsy in sarcoidosis?

A

infiltration of alveolar walls and interstitial spaces with mononuclear cells - later, granulomas

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33
Q

how does acute sarcoidosis present?

A

erythema nodosum ± polyarthralgia

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34
Q

give 3 pulmonary features of sarcoidosis?

A

dry cough, progressive dyspnoea, decreased exercise tolerance, chest pain.

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35
Q

give 3 extra-pulmonary features of sarcoidosis

A

lymphadenopathy, hepatomegaly, splenomegaly, uveitis, conjunctivitis, glaucoma, Bell’s palsy, neuropathy, meningitis, brainstem and spinal syndromes, space occupying lesions, erythema nodosum, cardiomyopathy, arrhythmias, hypercalcaemia, renal stones, pituitary dysfunction

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36
Q

what are the features of sarcoidosis on CXR?

A

bilateral hilar lymphadenopathy ± pulmonary infiltrates/fibrosis

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37
Q

list some differential diagnoses for bilateral hilar lymphadenopathy

A

sarcoidosis, infection (TB, mycoplasma), malignancies, silicosis, EAA

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38
Q

what investigations would you carry out, apart from CXR, in sarcoidosis, and what might they show?

A

SERUM ACE is raised.
lung function - restrictive pattern, reduced TLC, reduced FEV1/FVC ratio.
tissue biopsy - non-caseating granuloma.

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39
Q

how would you treat sarcoidosis?

A

if symptomatic - corticosteroids (prednisolone).

if severe - IV methylprednisolone or methotrexate.

40
Q

what is the underlying pathology of idiopathic pulmonary fibrosis?

A

disruption of alveolar epithelium and basement membrane activates inflammation.
fibroblasts convert to myofibroblasts - synthesise collagen and aggregate to form fibrotic foci.

41
Q

give 3 symptoms and 3 signs of idiopathic pulmonary fibrosis

A

symptoms - dry cough, exertional dyspnoea, malaise, weight loss, arthralgia.
signs - cyanosis, finger clubbing, fine end-inspiratory crepitations.

42
Q

what investigations would you carry out in idiopathic pulmonary fibrosis? what do they show? which one is needed for diagnosis?

A

CXR - ground glass appearance, decreased lung volume, bilateral lower zone reticulo-nodular shadows - honeycombing if severe.
lung function tests - restrictive pattern, increased FEV1/FVC ratio.
need a lung biopsy.

43
Q

what is the ultimate end treatment of idiopathic pulmonary fibrosis?

A

lung transplant

44
Q

name 3 causes of pulmonary hypertension

A

hereditary, SLE, systemic sclerosis, rheumatoid arthritis, drugs, HIV, portal hypertension, schistosomiasis, chronic haemolytic anaemia, COPD, pulmonary fibrosis, mitral valve disease, sarcoidosis

45
Q

define pulmonary hypertension

A

elevated pulmonary artery pressure (>25mmHg at rest) and secondary right ventricular failure

46
Q

give 3 clinical features of pulmonary hypertension

A

exertional dyspnoea, lethary, peripheral oedema, loud pulmonary second sound, right parasternal heave

47
Q

give 3 signs that pulmonary hypertension has progressed to right heart failure (cor pulmonale)

A

elevated JVP, hepatomegaly, pulsatile liver, peripheral oedema, ascites, pleural effusion

48
Q

what is the eventual end treatment of primary pulmonary hypertension?

A

heart and lung transplant

49
Q

what 3 investigations would you carry out in pulmonary hypertension and what would they show?

A

CXR - enlarged proximal pulmonary arteries which taper distally.
ECG - RVH, P pulmonale (peaked P waves)
Echo - RV dilation/hypertrophy

50
Q

how would you treat pulmonary hypertension?

A

warfarin - reduce thrombosis risk.
diuretics - oedema.
oral CCBs - pulmonary vasodilators

sidenafil (PDE5 inhibitor) for primary pulmonary hypertension

51
Q

what is a haemothorax?

A

blood in the pleural space

52
Q

what is a chylothorax?

A

chyle (lymph + fat) in the pleural space

53
Q

what is an empyema?

A

pus in the plerual space

54
Q

what is a pleural effusion? define transudates and exudates

A

fluid in the pleural space
transudates = low protein content
exudates = high protein content

55
Q

give 3 causes of a transudate pleural effusion

A

cardiac failure, constrictive pericarditis, fluid overload, cirrhosis, nephrotic syndrome, malabsorption, hypothyroidism.

increased venous pressure and fluid overload.

56
Q

give 3 causes of an exudate pleural effusion

A

pneumonia, TB, rheumatoid arthritis, SLE, bronchogenic carcinoma, malignant metastases, lymphoma, mesothelioma, lymphangitis carcinomatosis.

increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy.

57
Q

what would you hear on auscultation of a patient with a pleural effusion?

A

on side of the effusion:

decreased expansion, stony dull percussion note, diminished breath sounds.

58
Q

what investigations would you perform to diagnose a pleural effusion? what would they show?

A

CXR - small effusions blunt the costophrenic angles. larger = water-dense shadows with concave upper borders.
diagnostic pleural aspiration (US guided) - send for clinical chemistry, bacteriology and cytology.

59
Q

how would you treat a symptomatic pleural effusion?

A

drain it, repeat if necessary

60
Q

how would you treat recurrent pleural effusion?

A

pleurodesis with tetracycline, bleomycine or talc.

smoking cessation.

61
Q

what group of people are most likely to have a spontaneous pneumothorax?

A

young, thin men - rupture of sub-pleural bulla

62
Q

what is a pneumothorax?

A

air in pleural space, leading to partial or complete collapse of the lung

63
Q

what is a tension pneumothorax? how does it present?

A

pleural tear acts as a one way valve - air passes through during inspiration but is unable to exit during expiration.

presents in patient on mechanical ventilation - unilateral increase in pleural pressure with increasing respiratory distress - then shock - then cardiorespiratory arrest

64
Q

give 3 causes of a pneumothorax

A

spontaneous, chest trauma, asthma, COPD, TB, pneumonia, lung abscess, carcinoma, cystic fibrosis, lung fibrosis, sarcoidosis, connective tissue disorders (Marfan’s, Ehler-Danos)

65
Q

give 3 signs of a pneumothorax

A

reduced expansion, hyper-resonance to percussion, diminished breath sounds on affected side.

(in tension pneumothorax, trachea deviates away from the affected side)

66
Q

how would you manage a pneumothorax?

A

chest drain - urgent.

67
Q

give 3 risk factors for bronchus carcinoma

A

smoking, asbestos, chromium, arsenic, iron oxides, radiation (radon gas)

68
Q

which bronchial carcinoma is more common in non-smokers?

A

adenocarcinoma

69
Q

what cells do small cell lung cancers arise from? what can be the side effects of this?

A

endocrine cells (enterochromaffin cells) - carcinoid syndrome - flushing, diarrhoea, hyponatraemia

70
Q

which type of bronchial carcinoma is most likely to cause an obstruction?

A

squamous cell carcinoma

71
Q

describe the features of a squamous cell bronchial carcinoma

A

35%.
mostly present as obstructive lesion leading to infection.
occasionally cavitates. local spread common.
widespread metastases occur late.

72
Q

describe the features of an adenocarcinoma of the bronchus

A 
27%.
most common lung cancer associated with asbestos exposure. 
more common in non-smokers.
usually occurs peripherally.
local and distant metastases.
73
Q

what are the features of a large cell bronchial carcinoma?

A

10%.

poorly differentiated tumour, metastasizes early.

74
Q

which type of bronchial carcinoma generally has a worse prognosis, NSLC or SCLC?

A

small cell

75
Q

give 3 symptoms of bronchial carcinoma

A

cough, haemoptysis, dyspnoea, chest pain

76
Q

give 3 signs of bronchial carcinoma

A

cachexia, anaemia, clubbing, HPOA (hypertrophic pulmonary osteoarthropathy), supraclavicular or axillary nodes.
chest signs - none, or consolidation/collapse/pleural effusion

77
Q

give 3 examples of signs that there are distant mets in bronchial carcinoma

A

bone tenderness, hepatomegaly, confusion, fits, focal CNS signs, cerebellar syndrome, proximal myopathy, peripheral neuropathy

78
Q

give 3 local complications of bronchial carcinoma

A

recurrent laryngeal nerve palsy, phrenic nerve palsy, SVC obstruction, Horner’s syndrome, rib erosion, pericarditis, AF

79
Q

give 3 neurological complications of bronchial carcinoma

A

confusion, fits, cerebellar syndrome, proximal myopathy, neuropathy, polymyositis

80
Q

list the differential diagnoses of a nodule on the lung seen on CXR

A

malignancy, primary or secondary; abscesses, granuloma, carcinoid tumour, pulmonary hamartoma, arterio-venous malformation, encysted effusion (fluid, blood, pus), cyst, foreign body, skin tumour

81
Q

where do bronchial adenocarcinomas most commonly metastasise to?

A

mediastinal lymph nodes, brain, bone, adrenals

82
Q

how would you investigate a possible bronchial carcinoma?

A

sputum and pleural fluid samples for cytology.
CXR.
fine needle aspiration or biopsy.
bronchoscopy, CT, PET.

83
Q

list some possible features of a CXR of a patient with bronchial carcinoma

A

peripheral nodule, hilar enlargement, consolidation, lung collapse, pleural effusions, bony secondaries (e.g. ribs).

84
Q

what staging system is used for bronchial carcinomas?

A

TNM.
T = tumour, N = nodes, M = distant metastases.
converted into stage I-IV.

85
Q

how would you treat NSCLC?

A

peripheral tumours, stageI/II - surgical excision.
or, curative radiotherapy.
more advanced disease = chemo ± radiotherapy

86
Q

how would you treat small cell lung cancer?

A

may respond to chemo, but will relapse.
cyclophosphamide + doxorubicin + vincristine + etoposide.
OR cisplatin ± radiotherapy.

87
Q

describe some features of palliative care given to patients with bronchial carcinoma

A

radiotherapy - bronchial obstruction, haemoptysis, bone pain, cerebral mets.
SVC stent + radio - SVC obstruction.
pleural drainage.
analgesia, steroids, antiemetics, codeine for cough etc.

88
Q

name two benign lung cancers

A

bronchial adenoma, hamartoma

benign mesothelioma

89
Q

what is the biggest cause of mesothelioma?

A

occupational ASBESTOS exposure

90
Q

what is mesothelioma?

A

tumour of mesothelial cells that usually occurs in the pleura

91
Q

how would you diagnose mesothelioma?

A

CXR/CT - pleural thickening/effusion.
bloody pleural fluid.
histology following thoracoscopy - often only diagnosed postmortem.

92
Q

how would you treat mesothelioma?

A

chemo - cisplatin + premetrexed

93
Q

what are the two main features of Goodpasture’s disease?

A

acute glomerulonephritis + lung symptoms

94
Q

what are the pulmonary features of Goodpasture’s disease?

A

cough, intermittent haemoptysis, anaemia, upper respiratory tract infecions

95
Q

what investigation would you need to confirm a diagnosis of Goodpasture’s disease?

A

kidney biopsy - crescenteric glomerulonephritis

96
Q

how would you treat Goodpasture’s disease?

A

immunosuppression (corticosteroids) + plasmapheresis to remove antibodies

97
Q

what causes the features of Goodpasture’s disease?

A

anti-glomerular basement membrane antibodies - bind to kidney basement membrane and alveolar membrane

Respiratory (9 decks)

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