Respiratory Flashcards
Signs of pleural effusion on inspection (2)
Trachea and apex beat deviated to opposite side if large
Reduced chest expansion
Signs pleural effusion on auscultation (3)
Reduced vocal resonance
Reduced or absent breath sounds
May be bronchial breathing heard above effusion
Sign pleural effusion on percussion
Stony dull
2 broad causes of pleural effusion
Transudate
Exudate
What is exudate
At least one of light’s criteria
High protein - fluid protein: serum protein more than 0,5
High LDH- fluid LDH: serum LDH more than 0,6 or more than 2/3 normal upper limit LDH in serum.
= local problem eg malignancy, inflammation, pulmonary infarct , chemo and radiation
What is transudate
Transported fluid from elsewhere to pleural space
= systemic problem eg hf, hypoproteinaemia
causes transudative pulmonary effusion 3
Hypothyroid
Hypoalbuminaemia eg from cirrhosis, kidney failure
Cardiac failure
6 causes exudative pleural effusion
Malignancy: bronchial carcinoma, metastatic carcinoma…
TB
Pneumonia
Meigs syndrome -ovarian fibroma causing pleural effusion and ascites
Connective tissue disease-rheumatoid arthritis, SLE
Acute pancreatitis
Chemo /radiation
Pulmonary infarct
What is consolidation
Lobar pneumonia
Chest inspection findings of consolidation
Reduced chest wall movement (expansion)
Percussion signs of consolidation
Dull
Auscultation findings of consolidation (4)
Bronchial breathing Coarse crackles inspiratory Vocal resonance increased Reduced breath sounds. (Pleural rub may be present)
Symptoms of consolidation (6)
Dementia! Cough (painful and dry at first) Fever and rigors Pleuritic chest pain Dyspnoea Tachycardia
Diagnosis COPD?
Spirometry: post-bronchodilator FEV 1 / FvC <70%
What is emphysema
Increase in air spaces distal to terminal bronchioles (alveoli) (hyperinflation)
Inspection signs of COPD chest (4)
Barrel- shaped chest (hyperinflation)
Use of accessory muscles
Hoover’s sign
Reduced expansion
Lay term for emphysema patients
Pink (face) puffers (dyspnoea)
Face and neck signs copd (3)
emphysema
• Pink face
• Pursed -lip breathing
• tracheal tug
Chronic bronchitis
• central cyanosis later
Reduced cricosternal distance
Raised JvP
Complications of COPD (2)
Emphysema
•Hypercapnia - drowsy/ coma state. May be caused by oxygen supplements which further diminishes respiratory drive. Also lead to warm peripheries, bounding pulses, flapping tremor
Chronic bronchitis
• R ventricular failure
Chest percussion signs COPD (2)
Hyper-resonant
Emphysema: decreased liver dullness
Auscultation COPD signs (3)
Decreased breath sounds
Early inspiratory crackles
Chronic bronchitis: wheezes
Heart sounds loudest in epigastrum
Lay term for chronic bronchitis patients
Blue (cyanosis) bloaters (oedema from right ventricular failure)
What is Chronic bronchitis definition
Daily production of sputum for 3 months a year for at least 2 consecutive years. Subtype of COPD.
Symptoms of Chronic bronchitis (2)
Loose cough and sputum esp in morning
Oedema
Classic symptoms of TB (5)
Cachexia or weight loss Night sweats Cough Hemoptysis Malaise
Name 4 risk factors for pulmonary embolism
Previous PE
Immobilisation
Known clotting factors abnormalities
Known malignancy
Hand signs of Chronic liver disease (5)
Leuconychia Clubbing Palmar erythema! Bruising Asterixis (flapping tremor)
Face signs of chronic liver disease (4)
Jaundice
Scratch marks (itch) ( higher levels bile salts under Skin)
Spider naevi
Fetor hepaticus (breath strong, musty dead smell-liver not clearing toxins)
Chest signs of Chronic liver disease (5)
Gynecomastia Loss body hair Spider naevi Bruising Pectoral muscle wasting
Abdomen and genital signs Chronic liver failure (4)
Hepatosplenomegaly
Ascites
Signs of portal hypertension (splenomegaly, collateral veins: haematemesis from oesoph/gastric varies, ascites)
Testicular atrophy
Leg signs of chronic liver disease (3)
Oedema
Muscle wasting
Bruising
Signs of liver cirrhosis (10)
- Encephalopathy!!!
- jaundice
- Palmar erythema!
- endocrine: loss libido, hair loss; men: gynaecomastia, testicular atrophy, impotence; women: breast atrophy, irregular menses, amenorrhaea
- PHT: Prominent abdominal veins!!!!, splenomegaly, variceal bleeding
- haemorrhagic: bruises, purpura, epistaxis
- Ascites!!
- Spider naevi!, cyanosis
- pigmentation, clubbing, Dupuytren’s contracture
- Hepatomegaly at first and firm
(2 or more = strong suggestion cirrhosis)
Define pulmonary HT
Mean pulmonary a pressures >25 and systolic pressures >50
Harrison sulcus vs hoover sign (3)
Hoover for balloon
- chronic vs acute
- sign of abnormally weak bones (eg rickets) or chronic respiratory disease (eg chronic severe asthma) vs sign of hyperinflation
- in drawing of ribs by diaphragm at lower end of rib cage at 6th rib during inspiration and expiration vs flat diaphragm causing pulling in of inferior ribs on inspiration bc diaphragm contract inward instead of downward
Name and describe the score used for pneumonia clinical prediction for admission
Curb 65 score
- Confusion (1 point)
- Urea > 7 mmol/l or BUN > 20 mg / dl (blood urea nitrogen) (1 point)
- respiratory rate > 30 (1 point)
- blood pressure systolic < 90 or diastolic <60 ( 1 point)
- age 65 or older (1 point)
Score 0-1 < 5% mortality: treat as outpatient
2-3 5-15%: admit
4 -5 15-30%: admit to ICU
Which criteria is used to determine if pleural effusion is exudative or transudative? Describe.
Lights criteria for exudative effusion - at least one: (otherwise transudative)
( PLeural effusion )
- Protein pleural fluid: protein serum > 0,5
- LDH fluid: LDH serum > 0,6
- LDH pleural fluid > 2/3 normal upper limit of LDH in serum
Clinical classification of pneumonia? (4)
- Community acquired
- nosocomial
- aspiration
- occurring in immunocompromised patient eg PCP
Anatomical classification of pneumonia? (3)
- Lobar ( alveoli infected)
- bronchopneumonia
- interstitial
Name 3 infective causes lobar pneumonia
- Streptococcus pneumonia most common
- klebsiella pneumonia (usually upper lobes)
- legionella
Name 3 infective causes bronchopneumonia
Wide variety bacteria eg mycoplasma, chlamydia, staph, pseudomonas
Name 3 infective causes interstitial pneumonia
- Viruses
- PJP
- mycoplasma pneumonia
Common viral cause community acquired pneumonia?
Influenza
Common bacteria cause community acquired pneumonia? (6)
Cause 75% of all community acquired pneumonias
Pyogenic
- streptococcus pneumonia (most common, 50%)
- haemophilus influenza (esp smokers)
- staphylococcus aureus
Atypical
- mycoplasma pneumonia (10%)
- chlamydophila pneumonia (10.%.)
- legionella pneumophila
Treatment mild pneumonia with CURB65 0-1?
- Amoxicillin 500mg TDS
Or
- clarithromycin 500 mg bd
Treatment moderate pneumonia with CURB65 3?
Amocycillin 500mg TDS
And
Clarithromycin 500mg bd
Treatment moderate pneumonia with CURB65 3?
Amocycillin 500mg TDS
And
Clarithromycin 500mg bd
Treatment severe pneumonia with CURB65 3 or more or clinically?
CoamoxiclaV 1,2g TDS (penicillin + b lactam) (augmentin)
And
Clarithromycin 500 MG bd (macrolide)
For 5 days
Define respiratory failure
Pa 02 < 60 mmhg ( < 8kpa )
Type 1 vs 2 respiratory failure? (4)
Both hypoxia paO2 < 60 mmhg
Type 1
- normal / low paco2
- caused by vq mismatch eg pneumonia, pulmonary oedema, pe, asthma,emphysema, ARDS
Type 2
- hypercapniA PACO2 > 45 mmhg (>6 kpa)
- caused by alveolar hypoventilation with or without Vq mismatch eg pulmonary disease (asthma, COPD, pneumonia, OSA, pulmonary fibrosis) , reduced resp drive (sedatives,CNS tumour,trauma), neuromuscular disease (cervical cord lesion, poliomyelitis, myasthenia gravis, GBS ), thoracic wall disease (flail chest)
Define tachypnoea
> 25 bpm
What is pancoast’s syndrome
Apical lung cancer + ipsilateral horner’s from invasion of cervical sympathetic plexus
Name causes bronchiectasis (10)
Post Infective
- pneumonia!: H influenza, strep pneumonia, S aureus, pseudomonas aeruginosa !, klebsiella
- bordetella pertussis
- Tb!
- HIV
- viral: measles (rubeola), bronchiolitis (rsv)
- fungal: allergic bronchopulmonary aspergillosis
Non infective
- congenital: cystic fibrosis, primary ciliary dyskinesia, alpha 1 antitrypsin deficiency
- bronchial obstruction
- hypogammaglobulinemia, ulcerative colitis
- rheumatoid arthritis
Name 3 symptoms bronchiectasis
- persistent Cough
- copious purulent sputum
- intermittent haemoptysis
Name 5 complications bronchiectasis
- Pneumonia (frequent infections bc dilation airways → can’t clear airway)
- pleural effusion, pneumothorax
- haemoptysis
- Cerebral abscess
- Amyloidosis
CXR features bronchiectasis? (3)
- Cystic shadows - honeycomb sign
- thickened bronchial walls: tramline and ring shadows
Name 4 causes pulmonary oedema
- Cardiovascular: LHF! (Post mi or ihd), mitral stenosis, arrhythmia, malignant hypertension
- Ards
- fluid overload
- neurogenic eg head injury
Symptoms pulmonary oedema (3)
- Dyspnoea
- pink frothy sputum
- orthopnoea
Signs pulmonary oedema (4)
- General:, distressed, pale, sweaty, sitting up + leaning forward
- vitals: decreased oxygen saturations! Tachypnoea! Tachycardia
- CvS: raised JvP! Pulses alternans, s3 gallop
- resp: pink frothy sputum, fine crackles!, wheeze (cardiac asthma)
Define ARDS
Diffuse neutrophilic alveoli’s caused by range of conditions, characterised by
- bilateral radiographic infiltrates and
- hypoxaemia
Name 10 causes ARDS
Pulmonary
- pneumonia
- gastric aspiration
- inhalation
- injury eg transfusion related (trali), contusion
- vasculitis
Abdomen
- acute liver failure
- Pancreatitis
- malaria
Drugs / toxins
- aspirin
- heroin
- chemo
Other
- shock
- septicaemia
- haemorrhage
- DIC
- trauma, head injury, burns
- fat embolism
- obstetric events eg eclampsia, amniotic fluid embolism
Diagnostic criteria ARDS (4)
All 4:
- Acute onset
- Bilateral infiltrates on CXR
- PCwP (pulmonary capillary wedge pressure to see of LHF by catheter ) < 19 mmhg or a lack of clinical CCF
- Refractory hypoxaemia with Pa02: fio2 < 200
+/- total thoracic compliance < 30ml / cm H2O
ARDS = Acute, refractory hypoxia, diffuse CXR infiltrates, Schwann catheter PCWP <19
Management ARDS? (8)
Treat underlying cause.
- Oxygen! + CPAP ; but most need mechanical ventilation (lung protective: low tidal volumes 4-8 ml/kg, peep, )
- circulatory support:
→ invasive monitoring with arterial line and swan-ganZ catheter to aid diagnosis and monitor PCwP
→ conservative fluids
→ maintain cardiac output and oxygen delivery with inotropes eg dobutamine, vasodilators, transfusion
→ consider treating PHT with low dose nitric oxide (pulmonary vasodilator) - enteral nutritional support with high fat, antioxidant formulations
- steroids treat those at risk for fat embolism and with pneumocystOsis and may improve outcome
Diagnosis Mac? (6)
Diagnosis of exclusion!
Clinical criteria
- pulmonary symptoms or
- nodular/ cavitary opacities on CXR or
- high resolution Ct with multifocal bronchiectasis with multiple small nodules
Microbiological criteria
- At least 2 expectorated sputum samples or
- 1 bronchial lavage or
- lung biopsy positive for non-tb mycobacterium with mycobacteria histopathological features
- if disseminated MAC, use culture from bone marrow/ lymph node/blood ( sputum unreliable)
Treatment mycobacterium avium complex
- Azithromycin or clarithromycin (don’t use if on arvs) and
- ethambutol
For 12 months , only stop if CD4 % > 15%
If poor response, add rifabutin, ciprofloxacin
Prevention MAC
Start prophylaxis when CD4 <50
Azithromycin or clarithromyCIN or rifabutin
Label spirogram picture 7
See picture 8
Name 5 causes /mechanisms arterial hypoxaemia and give 2 examples each
- Low inspired oxygen: high altitude, air flight
- hypoventilation: CNs depressant drugs, cenebrovascular accident, head injury
- diffusion impairment: interstitial lung disease, emphysema, pe, PHT
- vq mismatch: COPD, atelectasis, ARDS, pulmonary oedema
- R to l shunt: eisenmenger syndrome, pulmonary av malformation
What is the alveolar arterial gradient?
A-a = PA O2 (alveolar pressure of oxygen ) calculated - pao2 on blood gas
How calculate PAo2 (alveolar pressure of oxygen)
PaO2 = pio2 (partial pressure of inspired oxygen) - paco2 / rq (respiratory quotient)
PiO2 = fio2 (patm - PH2O)
How is the pf ratio (pao2/fi02) used in classifying hypoxia
<300 = moderate
< 200 = severe
Pleural fluid characteristics of complicated parapneumonic effusion eg empyema? (2)
- Ph<7,2
- positive gram stain /culture
Pleural fluid characteristics of chylothorax? (2)
- Triglycerides > 110 mg/ dL
- Presence of chylomicrons
Aka lymph, causes = trauma, congenital lymphatic malformations, tumours, Tb
Name 4 causes lymphocytic pleural exudate
- Tb
- lymphoma
- sarcoidosis
- rheumatoid arthritis
- post coronary artery bypass grafting chylothorax
- Yellow nail syndrome: abnormal lymphatics. Triad yellow nails, lymphoedema,pulmonary sx
Name 4 causes eosinophilia pleural exudate (>10% eosinophils)
- Malignany: lung cancer
- infection: Fungal disease, parasitic disease eg paragonimiasis most common, amebiasis
- Churgg - Strauss syndrome
- pleural irritation: pneumothorax, haemothorax, asbestos
- drug induced effusions: warfarin, simvastatin
Which bacteria would be suspected in pneumonia in an alcoholic? (2)
- Strep pneumo!
- Gram negatives: klebsiella pneumonia, H influenza (alcohol alters oropharyngeal flora so G- colonise more )
Which bacteria would be suspected in pneumonia in aspiration (2)
- Gut bacteria eg bacteroïdes
- enteric G -: E. coli
- gastric contents: chemical pneumonitis
- bacteria in oral cavity: S aureus, strep pneumococcus
Risk Score used for pulmonary embolism?
Wells score (uses clinical suspicion, no other dX likely, hr, immobilisation/ surgery, history, haemoptysis, malignancy) - need 3 RFs, 3 symptoms, 1 other
Or Geneva score
Risk Score used for pulmonary embolism?
Wells score (uses clinical suspicion, no other dX likely, hr, immobilisation/ surgery, history, haemoptysis, malignancy) - need 3 RFs, 3 symptoms, 1 other
Or Geneva score
Diagnostic approach pulmonary embolism? (5)
Assess clinical probability: wells score
Low to moderate probability: do D dimer (-ve excludes it)
→ positive: vq scan if normal CXR (perfusion defects with no corresponding ventilation defects),
→ inconclusive: CTPA
High probability: straight to CTPA. If contraindication, do vq scan. If this can’t be done, do Mr angiography/tee / digital subtraction angiography
CXR findings pulmonary embolism? (7)
- May be normal.
- oligaemiA of affected segment (Westermark’s sign)
- dilated pulmonary artery ( Pallas sign)
- horizontal linear plate atelectasis, usually lower zone
- elevated hemi diaphragm
- small pleural effusion
- wedge shaped opacities or cavitation (Hampton’s hump )
- pulmonary opacities
- Fleischner’s sign: prominent amputated pulmonary artery
Normal CXR = more likely pa. More abnormal = less likely
Treatment pulmonary embolism?
• Low molecular weight heparin eg enoxaparin (clexane) subcutaneous 1 mg/kg bd
• warfarin oral initially 5 mg daily for 2 days then titrate according to INR. Maintenance dose usually 2,5-10 mg daily.
Start both at the same time due to initial pro-coagulant effect of warfarin for the first 3 days.
Stop heparin once INR reaches therapeutic range of 2-3 for 2 consecutive days
Continue warfarin for
-6 months If first episode of idiopathic DVT
-3 months if reversible cause
-12 months if thrombophilic disorders or antiphospholipid antibodies
- indefinitely for patients above and recurrent DVT
Consider vena cava filter.
Pulmonary hypertension causes? (5)
- Idiopathic or connective tissue disease eg SLE
- L HF: usually from mi or ht
- chronic lung disease and/or hypoxaemia: COPD, OSA, ILD, pulmonary fibrosis, high altitude
- Pulmonary vascular disease eg pe (causes acute cor pulmonAle)
- Miscellaneous: sarcoidosis, glycogen storage disease, haemotological disorders eg sickle cell, thoracic cage abnormality eg kyphosis, neuromuscular disease eg myasthenia
Typical clinical findings pulmonary hypertension?
- Loud pulmonary component of s2 @ L heart! Almost definitive.
- s3
- Pansystolic murmur from tr + diastolic from Pr
Later:
- parasternal heave (RVH)
- raised JVP with prominent A wave
- ascites, peripheral oedema, hepatomegaly
Diagnosis cor pulmonale?? (4)
- Bloods: increased hb and Hct (secondary polycythaemia), hypoxia +/-hypercapnia
- CXR: enlarged ra+ rv ( loss retrosternal space), prominent pulmonary arteries
- ECG: p pulmonale (narrow + peaked P waves) , r axis deviation, rvh/strain
- Doppler echo: rv enlarge, dilation coronary sinus, measure pa pressure
- right heart catheterisation
How is asthma graded?
NAEPP grading
- intermittent asthma: symptoms 2 or less/week, wake up from symptoms 2 or less /month , no interference daily activities, use SABA 2 or less/week. Normal lung function. 1 or less exacerbations / year requiring systemic steroids.
- mild persistent: symptoms > 2 /week, wake up 3-4/month, saba > 2 /week, minor limitation. Normal lung function. Exacerbations 2 or more / year
- moderate persistent: daily symptoms. Wake up > 1/week. Some limitation. Daily use SABA. FEV1 60-80% predicted, decrease FEV 1 : FVC by < 5%. Exacerbations as above.
- severe persistent: daily symptoms, wake up every night, extreme limitation, use SABA several times per day. FEV 1 < 60% predicted, decrease FEV 1 : FVC by > 5%. Exacerbations as above
Spirometry findings asthma?
- Obstructive defect: decrease FEV 1 : FVC, increase residual volume.
- > 15% improvement FEV 1 following bronchodilator
Stepwise treatment chronic asthma according to NAEPP? (6)
- Intermittent asthma: saba eg salbutamol only
- Mild persistent: add low dose ICS or rescue ics-saba only (alternative = LTRA eg montelukast)
- Moderate persistent: low dose ics (eg beclomethasone)- formoterOl (laba)
- Mod to severe persistent: medium dose ICS - formoterol
- Severe persistent: medium - high dose ICS - LABA + lama (tiotropium bromide )
- Severe persistent: high dose ICS - LABA + oral corticosteroids (prednisone). Consider biologics eg omalizumab.
Define controlled asthma (5)
- No daytime symptoms or nighttime waking due to asthma
- No asthma attacks or need for rescue medications
- No limitations on activity
- normal lung function
- minimal side effects
How assess severity acute asthma attack? (4)
- Mild asthma exacerbation: dyspnoea on exertion. Tachypnoea, wheezing on end exhalation. Pefr 70% or more than predicted, sp02 95% or more.
- moderate: dyspnoea At rest, can talk in phrases, agitated,prefer sit up > lie down. Loud wheezing, accessory muscles, tachycardia <120. Pefr 40 - 69%, sp 02 90-95%
- severe: talk in words, tripod position. Severe tachypnoea > 30, inspiratory+ expiratory wheeze, tachycardia > 120, pulsUs paradoxus (fall bp inspiration > 10). Pefr <40%, spo2 < 90%, hypercapnia paco2 >42
- life threatening: can’t talk, drowsy, confused sweating. Silent chest, paradoxical breathing, bradycardia, altered mental status. Pefr <25%, signs respiratory failure.
Treatment mild asthma exacerbation?
Saba + oral corticosteroids if necessary
Treatment moderate asthma exacerbation?
- Oxygen
- saba
- oral corticosteroids
Treatment severe asthma exacerbation? (4)
- High dose oxygen 100% via non -rebreathing bag
- salbutamol 5 mg + ipratropium bromide 0,5 mg nebulized with oxygen
- hydrocortisone 100 mg iv or prednisolone 40 -50mg po or both if very ill
- if not improving: mgso4 1,2 - 2g iv over 20 min. Consider aminomphylline or salbutamol iv
(Cxr to exclude pneumothorax)
Treatment life-threatening asthma exacerbation? (4)
- High dose oxygen 100% via non -rebreathing bag, consider early intubation
- salbutamol 5 mg + ipratropium bromide 0,5 mg nebulized with oxygen every 15 min
- hydrocortisone 100 mg iv or prednisolone 40 -50mg po or both if very ill
- mgso4 1,2 - 2g iv over 20 min.
Consider aminomphylline or salbutamol iv if not improving. Transfer to ICU
Normal pao2?
80 - 100
Name 7 clinical features pulmonary fibrosis
Inspection
- central cyanosis
- tachypnoea
- clubbing in idiopathic pulmonary fibrosis
- raised JVP and peripheral edema iF cor pulmonale
Palpation
- reduced expansion (small lungs)
Percussion
- dull at bases (high diaphragm)
auscultation
- fine inspiratory crackles at bases
How is empyema confirmed (3)
- Fluid thick + turbid pus
- glucose < 3,3
- Ldh > 1000
- pH < 7
Describe the modified medical research council (mrc) dyspnoea scale for COPD
- Grade o: only with strenuous exercise
- grade 1: when hurrying on level or walking up slight hill
- 2: walk slow due to breathlessness, or has to stop to catch breath
- 3: stop for breath after walk 100m or few minutes on level ground
- 4: too breathless to leave house, breathless when dress
Name signs bronchiectasis
- iF no secretions and no lobar collapse, normal physical exam
- copious secretions → coarse crackles
- collapse with retained secretions blocking a proximal bronchus → locally diminished breath sounds
Name 10 complications cystic fibrosis
Respiratory
- progressive airway obstruction
- infective exacerbations of bronchiectasis
- respiratory failure
- spontaneous pneumothorax
- haemoptysis
- Lobar collapse due to secretions
- PHT
- nasal polyps
Abdominal
- malabsorption, steatorrhoea!
- distal intestinal obstruction syndrome
- pHt, varicies, splenomegaly
- biliary cirrhosis
- gallstones
Other
- diabetes!
- delayed puberty, male infertility
- stress incontinence due to repeated forced cough
- psychosocial problems
- osteoporosis, arthropathy
- Cutaneous vasculitis
Differential of pneumonia? (6)
- Pulmonary infarction
- pulmonary/ pleural TB
- pulmonary oedema (can be unilateral)
- pulmonary eosinophilia
- malignancy: bronchOalveolar cell carcinoma
- cryptogenic organising pneumonia / bronchiolitis obliterans organising pneumonia (cop/boop)
Which community acquired pneumonia is more common in young
Mycoplasma pneumonia
Which community acquired pneumonia is more common in elderly
Haemophilus influenza
Which community acquired pneumonia is more common in alcoholics
Klebsiella pneumonia
Name 10 complications pneumonia
- Para-pneumonic effusion: common
- empyema
- retention of sputum causing lobar collapse
- DvT and pulmonary embolism
- pneumothorax, especially with S aureus
- suppurative pneumonia / lung abscess
- ARDS, renal failure, multi organ failure
- Ectopic abscess eg S aureus
- hepatitis, pericarditis, myocarditis, meningoencephalitis
- arrhythmic
- pyrexia due to drug hypersensitivity
Which drug should be prescribed with isoniazid
Pyridoxine for peripheral neuropathy
Name 4 types /causes diffuse parenchyma (interstitial) lung diseases
- Known cause eg drugs, connective tissue disease
- Granulomatous DPLD eg sarcoidosis
- other forms eg lymphangiolieomyomatosis, histiocytosis X
- idiopathic interstitial pneumonia
→ idiopathic pulmonary fibrosis
→ idiopathic interstitial pneumonia other than idiopathic pulmonary fibrosis: desquamative intersitial pneumonia ( male smokers), acute interstitial pneumonia (after viral urti), non-specific interstitial pneumonia, respiratory bronchiolitis interstitial lung disease, cryptogenic organising pneumonia, lymphocytic interstitial pneumonia (women)
Treatment interstitial pulmonary fibrosis
Pirfenidone (antifibrotic) or nintedanib (tyrosine kinase inhibitor)
Lung transplant
Name 7 possible presentations of sarcoidosis
- Asymptomatic: abnormal CXR (30%), abnormal LFT
- respiratory and constitutional symptoms (20-30%): ILD, bilateral hilar lymphadenopathy
- erythema nodosum and arthralgia (20 -30 % )
- Ocular symptoms (5-10 % ): anterior uveitis, sicca syndrome
- Skin sarcoid (including lupus pernio) (5 % )
- superficial lymphadenopathy 5%
- other 1%: hyper Ca, diabetes insipidus, CN palsy, cardiac arrhythmia, nephrocalcinosis
Diagnosis sarcoidosis?
Characteristic = lymphopenia
Confident diagnosis= erythema nodosum + bilateral hilar lymphadenopathy on CXR
Confirm = biopsy
May also have hyper Ca, hypercalciuria,
Name 4 drug causes ARDS
- Hydrochlorothiazide
- thrombolytic: streptokinase
- IV B agonists eg for premature Labour
- aspirin + opiate overdose
Name 4 drug causes alveolitis
- Amiodarone
- gold
- nitrofurantoin (UTI)
- cytotoxic: bleomycin, methotrexate, sulfasalazine
Name features of acute pulmonary embolism (5)
- Symptoms: faint/collapse, crushing chest pain, apprehension, dyspnoea, pleuritic chest pain, restricted breathing, haemoptysis
- sign: tachycardia, RHF if massive, pleural rub, raised hemidiaphragm, crackles, effusion,fever
- CXR: pleuropulmonary opacities, effusion, linear shadows, raised hemidiaphragm
- ECG: massive = S1Q3T3 anterior T wave inversion, rbbb; small/medium= sinus tachycardia
- ABG: low Pa O2 or paco2
Name 5 features chronic PE
- Symptoms: exertion dyspnoea, late = PHT / RHF
- sign: RHF: RV heave, loud p2
- CXR: enlarged pulmonary artery trunk, big heart, prominent RV
- ECG: massive = RV hypertrophy and strain
- ABG: exceptional low Pa O2
First line diagnostic test pulmonary embolism
CTPA
Define pulmonary hypertension
Mean pulmonary artery pressure 25 mm/ hg at nest
Classification/ causes pulmonary hypertension (5)
- Pulmonary artery ht: primary/ secondary (ctd, portal ht, HIV )
- pulmonary vein ht: left heart disease, pulmonary Veno - occlusive disease, pulmonary capillary haemangiomatosis
- pulmonary hypertension associated with disorders of respiratory system andor hypoxaemia: COPD, diffuse parenchyma lung disease, high altitude, sleep disordered breathing
- pulmonary hypertension caused by chronic thromboembolic disease: thromboembolic obstruction of proximal pulmonary arteries, sickle cell disease, in situ thrombosis
- miscellaneous: inflammation, extrinsic compression of central pulmonary veins
