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Year 3 > respiratory > Flashcards

respiratory Flashcards

1
Q

define asbestos related lung disease

A

industrial dust diseases

asbestosis:
- long term inflammation and scarring of lungs caused by asbestos fibre inhalation

mesothelioma:
- aggressive tumour usually occurring in pleural (sometimes peritoneum, pericardium, or testes)

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2
Q

epidemiology of asbestos-related lung disease

A

mesothelioma is rare - more common in elderly

asbestos exposure documented in 90% of cases

latent period between exposure and mesotheliomas = up to 50 yrs

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3
Q

aetiology of asbestosis

A

commonly used in building trade (always ask occupation)

degree of exposure related to degree of pulmonary fibrosis

inflammation gradually causes mesothelial plaques in pleura

causes increased risk of bronchial adenocarcinoma and mesothelioma

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4
Q

presenting symptoms of asbestosis

A

progressive dyspnoea

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5
Q

bloody sputum in asbestos related lung disease

A

mesothelioma

if tumour invades blood vessel

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6
Q

physical examination findings of asbestos related lung disease

A

asbestosis:
- clubbing
- fine end-inspiratory crackles

mesothelioma:
- occasional palpable chest wall mass
- clubbing (underlying asbestosis and pulmonary fibrosis)
- recurrent pleural effusions
- metastatic signs (lymphadenopathy, hepatomegaly, bone tenderness)
- abdominal pain/obstruction
- pneumothorax (rare)

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7
Q

investigations and findings for asbestosis

A

Hx and examination
CXR: reticular nodular shadowing +/- pleural plaques

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8
Q

aetiology of mesothelioma

A

associated with occupational exposure to asbestos - complex relationship

malignant pleural mesothelioma rarely spreads to distant sites
most patients present with locally advanced disease

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9
Q

presenting symptoms of mesothelioma

A 
SoB 
chest pain (dull, diffuse, developing)

weight loss
fatigue
fever
night sweats

bone pain
abdominal pain

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10
Q

investigations and findings for mesothelioma

A
  1. Ultrasound guided fluid aspiration
  2. staging CT
  3. Pleural biopsy (DIAGNOSTIC)

CXR/CT:
pleural thickening/effusion; pleural mass; rib destruction
* bloody pleural fluid

MRI + PET:

  1. ULTRASOUND GUIDED pleural fluid aspiration - send for cytological analysis
  2. pleural biopsy (DIAGNOSTIC)
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11
Q

Diagnosis of mesothelioma

A

histology following thoracoscopy (pleural biopsy)

biopsy can be immunostained with calretinin reactive stain

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12
Q

define lung cancer

A

primary malignant neoplasm of the lung

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13
Q

aetiology/risk factors of lung cancer

A

smoking
asbestos exposure
occupational hazards
atmospheric pollution

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14
Q

epidemiology of lung cancer

A

3x more common in males

scc = 20% 
nscc = 80%
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15
Q

presenting symptoms of lung cancer

A

due to primary tumour:

  • cough
  • haemoptysis
  • chest pain
  • dyspnoea
  • recurrent pneumonia

due to local invasion:

  • shoulder/arm pain (brachial plexus invasion)
  • hoarse voice and bovine cough (left recurrent laryngeal nerve invasion)
  • dysphagia
  • arrhythmias
  • horner’s syndrome

due to metastatic disease/paraneoplastic phenomenon:

  • weight loss
  • fatigue
  • bone pain
  • fractures
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16
Q

physical examination findings of lung cancer

A

may be no signs

fixed monophonic wheeze
signs of lobar collapse or PE

signs of metastases (lymphadenopathy, hepatomegaly, bone pain, etc.)

cachexia

anaemia

clubbing

hypertrophic pulmonary osteoarthropathy

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17
Q

investigations for lung cancer

A

for dx:
CXR
- peripheral nodule
- hilar enlargement
- consolidation
- lung collapse
- PE
- bony secondaries
sputum and pleural fluid cytology
bronchoscopy with brushings/biopsy (histology)
CT/US guided percutaneous biopsy
lymph node biopsy

for staging:
CT/MRI of head, chest, and abdomen
PET scan

radionuclide bone scan if suspected metastatic disease

lung function test (assess suitability of lobectomy)

bloods:
- FBC
- U&Es
- calcium (raised)
- ALP (raised with bone metastases)
- LFT

pre-operative ABG and pulmonary function test

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18
Q

prognosis of lung cancer

A

scc - worse prognosis than nscc

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19
Q

define obstructive sleep apnoea

A

recurrent prolapse of pharyngeal airway and apnoea during sleep followed by partial arousal

decreased tone of pharyngeal dilators during sleep

collapse of soft tissues of pharynx causes narrowing of upper airways

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20
Q

epidemiology of obstructive sleep apnoea

A

common
prevalence increases with age

associated with:

  • weight gain
  • smoking and alcohol
  • sedative use
  • macroglossia
  • marfan’s
  • craniofacial abnormalities
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21
Q

presenting symptoms of obstructive sleep apnoea

A

excessive daytime sleepiness
unrefreshing or restless sleep
morning headaches
dry mouth

difficulty concentrating
irritability and mood changes
decreased libido

snoring
nocturnal choking

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22
Q

physical examination findings in obstructive sleep apnoea

A

large tongue
enlarged tonsils
long/thick uvula
retrognathia

increased neck circumference (M>42cm, F>40cm)

obesity

hypertension

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23
Q

investigations for obstructive sleep apnoea

A

pulse oximetry
video recording

sleep study/polysomnography
- overnight monitoring
- airflow, respiratory effort, pulse oximetry, HR, snoring, and movement
* >15 episodes of apnoea/hypopnoea during 1hr of sleep = significant sleep apnoea

bloods:
- TFTs
- ABG

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24
Q

investigations for obstructive sleep apnoea

A

pulse oximetry
video recording

sleep study/polysomnography
- overnight monitoring
- airflow, respiratory effort, pulse oximetry, HR, snoring, and movement
* >15 episodes of apnoea/hypopnoea during 1hr of sleep = significant sleep apnoea

bloods:
- TFTs
- ABG

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25
Q

define pneumothorax

A

air in pleural space

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26
Q

aetiology/risk factors of pneumothorax

A

spontaneous:
- patients have typically normal lungs
- tall thin males
- caused by rupture of sub pleural bulla

secondary:
- in patients with pre-existing lung disease

traumatic:
- penetrating injury to chest
- often iatrogenic

risk factors:
- collagen disorders

tension pneumothorax

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27
Q

presenting symptoms of pneumothorax

A

may be asymptomatic if small

  • sudden onset SOB
  • pleuritic chest pain
  • distress with rapid shallow breathing in tension PTX

patients on ventilation may present with hypoxia/increase in ventilation pressures

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28
Q

physical examination findings of pneumothorax

A

may be no signs if small

  • respiratory distress signs (low O2 sats)
  • reduced expansion on affected side
  • hyper-resonance on affected side
  • reduced breath sounds on affected side
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29
Q

physical examination findings of tension pneumothorax

A
  • severe respiratory distress (low O2 sats, cyanosis)
  • tachycardia
  • hypotension
  • distended neck veins
  • tracheal deviation away from side of PTX
  • increased percussion note
  • reduced breath sounds
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30
Q

investigations for pneumothorax

A

CXR:
- darker area with no vascular markings (increased air)
- fluid levels if bleeding
* do not perform for suspected tension pneumothorax (can delay immediate necessary treatment)

ABG:
- check for hypoxaemia

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31
Q

management plan for tension pneumothorax

A

emergency

  1. needle decompression
  • large bore needle into 2nd ICS MCL on affected side just above 3rd rib
  • <2.5L of air can be aspirated
  • * stop if patient coughs/resistance felt
  1. High flow oxygen (max O2)
  2. chest drain

follow up CXR 2hrs and 2 wks later

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32
Q

management of primary pneumothorax

A

<2cm rim of air on CXR:

  • discharge
  • repeat CXR

>2cm +/- SoB:

  • aspiration
  • if unsuccessful => chest drain
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33
Q

management of secondary pneumothorax

A

<2cm:

  • aspiration
  • 24hr admittance

>2cm + SoB + >50yrs:
- chest drain

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34
Q

when to perform chest drain with underwater seal in pneumothorax case

A

if:
- aspiration fails
- fluid in pleural cavity
- after tension PTX decompression

inserted in 4-6th ICS MAL avoiding long thoracic nerve and artery

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35
Q

advice after pneumothorax

A

avoid air travel until follow up CXR
avoid diving/ subadiving

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36
Q

complications of pneumothorax

A

recurrent pheumothoraces (manage with chemical pleurodesis- fusing of visceral and parietal pleura with tetracyline/calcium or surgical pleurectomy)

bronchopleural fistula

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37
Q

prognosis of pneumothorax

A
  • after 1 PTX, ~20% will have another PTX
  • frequency increases with repeated PTX
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38
Q

define pulmonary embolism

A

dislodged thrombi occluding pulmonary vasculature

R heart failure and cardiac arrest potential if not aggressively treated

thrombus formation occurs as a result of Virchow’s triad

  • stasis of blood flow
  • trauma (blood vessel wall damage)
  • hyper coagulability
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39
Q

key diagnostic factors of pulmonary embolism

A
  • dyspnoea
  • PLEURITIC chest pain (pain on inspiration)
  • SUDDEN onset SOB
  • haemoptysis -blockage of artery
  • risk factors for PE (Hx - surgery, cancer, immobility-long flights, OCP, thrombophillia)
  • leg pain/ swelling => signs of DVT
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40
Q

Risk factors for PE

A
  • Immobility
  • Malignancy
  • Surgery
  • Trauma/ thrombophillia (too many platelets=> too much clotting)
  • Virchows triad (hypercoagulability- factor V leiden, vessel wall damage, stasis)
  • Pregnancy/ previous VTE/ OCP(DVT risks)
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41
Q

Examination signs of PE

A
  • tachypnoea (fast breathing)
  • hypertension
  • tachycardia
  • early (normal chest) => later (dullness to percussion from lobar collapse/ pleural effusion)
  • normal/reduced breath sounds
  • leg swelling (DVT)
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42
Q

investigations for pulmonary embolism

A

Bedside:

  • ECG- sinus tachycardia, RBBB (right heart strain)
  • Calculate risk (WELLSCORE >4, geneva score)

Bloods:

  • D-dimer (low = PE unlikely *due to clot breakdown)
  • FBC
  • U&Es
  • coagulation studies
  • LFT

Imaging:

  • CTPA (CT pulmonary angiogram)- detects an embolism DIAGNOSTIC
  • V/Q scan (for people who can’t have CTPA as radiation risk for pregnancy/ renal problems)
  • echo

consider:
- ABG (respiratory alkalosis => due to hyperventilation)
- CXR- exclude pneumothorax, pneumonia
- lower limb compression venous US
- cardiac biomarker
-

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43
Q

management of acute PE when haemodynamically unstable (bp <90 SBP)

A
  1. A=> E approach: respiratory support (oxygen, non-rebreather mask) + fluid resuscitation
  2. Urgent thrombolysis/ percutaneous embolectomy (with unfractionated heparin infusion)

consider:
- vasoactive drug
- surgical embolectomy/percutaneous catheter-directed treatment

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44
Q

management of acute PE when haemodynamically stable (SBP >90)

A
  1. risk stratify (Hestia score/ pulmonary embolism severity index)

Low risk

  1. high dose LMWH
  2. next 3 months - warfarin / DOACs (not for pregnant women)
  3. Outpatient follow up monitoring

Moderate/High risk

  1. Admit to hospital
  2. High dose LMWH
  3. Oxygen only if hypoxic
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45
Q

management after PE

A
  • continue long term anticoagulation
  • increase dose or switch to heparin if necessary
  • consider venous filter
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46
Q

definition of respiratory failure

A

acute impairment in gas exchange causing hypoxia with/without hypercapnia

PaO2 < 8kPa (type 1) + PaCO2 > 6.5kPa (type 2)

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47
Q

presentation of respiratory failure

A

SoB
anxiety
confusion
tachypnoea
cardiac dysfunction
cardiac arrest

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48
Q

key diagnostic factors of respiratory failure

A

risk factors

  • smoking
  • age
  • pulmonary infection

direct trauma to thorax and neck

cyanosis

dyspnoea

accessory muscle use

retraction of intercostal spaces

stridor

inability to speak

confusion

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49
Q

investigations for respiratory failure

A

pulse oximetry
ABG

FBC - elevated WBC?
D-dimer - rule out acute PE
serum bicarbonate
ECG - arrhythmias, MI, ischaemia, heart disease

CXR
pulmonary function test
urine/serum toxicology
chest CT
CTPA
V/Q scan
capnometry
cardiothoracic US

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50
Q

management of respiratory failure with airway obstruction

A

airway clearance

+ supplemental O2 (lower target if COPD)

+ treat underlying causes

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51
Q

management of stable respiratory failure without airway obstruction when conscious

A
  1. supplemental O2 (lower target if COPD)
    treat underlying causes
  2. +Ive pressure ventilation (NIV)
    treat underlying causes
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52
Q

management of stable respiratory failure without airway obstruction when unconscious

A
  1. supplemental O2 (lower target if COPD)
    treat underlying causes
  2. endotracheal intubation + mechanical ventilation
    rapid sequence induction
    treat underlying causes
53
Q

management of unstable respiratory failure without airway obstruction

A

supplemental O2 (lower target if COPD)

endotracheal intubation + mechanical ventilation

rapid sequence induction

treat underlying causes

54
Q

define sarcoidosis

A
  • chronic granulomatous disorder commonly affecting lungs, skin, and eyes
  • accumulation of lymphocytes and macrophages
  • non-caseating granulomas in lungs and other organs
  • unknown aetiology, heterogenous, and unpredictable
55
Q

risk factors for sarcoidosis

A

age 20 - 40 yrs
FHx
female
non-smokers

56
Q

symptoms and signs of sarcoidosis

A
  • non-specific (weight loss, chronic fatigue)
  • chest
    • cough
    • dyspnoea
    • haemoptysis
  • skin
    • erythema nodosum
    • lupus pernio
  • MSK - arthritis, joint pain
  • ocular - blurred vision, photophobia
57
Q

investigations for sarcoidosis

A
  • CXR
    • stage 0 = normal
    • stage 1 = bilateral hilar lymphadenopathy
    • stage 2 = bilateral hilar lymphadenopathy + pulmonary infiltrates
    • stage 3 = pulmonary infiltrates only
    • stage 4 = extensive fibrosis with distortion
  • Spirometry - restrictive
  • FBC- anaemia
  • serum urea and creatinine- renal injury
  • LFTs
  • serum calcium (high calcium)
  • ECG- arrhymias
  • PPD (purified protein derivative of tuberculin)
58
Q

management of sarcoidosis and ongoing pulmonary disease

A
  • observe
  • oral/inhaled corticosteroid
  • cytotoxics
  • oxygen (ventilatory support if ARF)
  • end stage = lung transplant

ocular/ CNS/PNS/ heart

  1. tropical/oral corticosteroids
  2. cytotoxics

cutaneous:

  1. topical corticosteroids
  2. hydroxychloroquine
59
Q

define bronchiectasis

A

chronic inflammation of bronchi and bronchioles => permanent dilatation and thinning

60
Q

main causative organisms of bronchiectasis

A
  • H influenzae
  • strep pneumoniae
  • staph aureus
  • pseudomonas aeruginosa
61
Q

causes of bronchiectasis

A

congenital

  • CF
  • primary ciliary dyskinesia
  • Young’s/kartagener’s syndrome- thick mucus prone to infection

aquired

  • childhood post-infection: measles, pneumonia, TB, HIV, whooping cough
  • allergic bronchopulmonary aspergillosis (ABPA) - allergic reation to mould
  • inflammation: RA, ulcerative colitis
  • bronchial obstruction
  • idiopathic
62
Q

symptoms of bronchiectasis

A
  • persisent cough
  • large amount of purulent sputum (yellow/green/brown)
  • intermittent haemoptysis
  • SOB +/- wheeze
  • fatigue fever chills
63
Q

signs of bronchiectasis

A
  • clubbing
  • coarse inspiratory crepitations
  • wheeze
64
Q

investigations for bronchiectasis

A

Bedside:

  • suptum culture (check for pseudomonas, s. aureus, H. infleunzae)

Bloods:

  • serum immunoglobulins
  • FBC
  • HIV
  • autoimmune screen (chronic inflammation)

Imaging

  • CT chest (dilated bronchioles) GOLD STANDARD
  • CXR - cystic shadows, thickened bronchial walls

Other

  • spirometry - obstructive pattern
  • bronchoscopy
  • CF sweat test
65
Q

management of bronchiectasis

A
  • CHEST PHYSIO (airway clearance techniques)
  • mucolytics - flutter valve
  • Antibiotics - pseudomonas = oral ciprofloxacin/suitable IV abx
  • bronchodilators - if comorbid asthma, COPD, CF, ABPA
  • corticosteroids - if ABPA
  • surgery - if localised disease, or to control severe haemoptysis
66
Q

complications of bronchiectasis

A
  • pneumonia
  • PE
  • pneumothorax
  • haemoptysis
  • cerebral abscess
  • anyloidosis
67
Q

define asthma

A
  • chronic inflammatory airway disease with reversible airway obstruction and hyper-reactivity

inflammation causes increased bronchial hyper-responsiveness and recurrent episodes of wheezing, breathlessness, chest tightness, and cough

reversible spontaneously or with treatment

68
Q

pathophysiology of asthma

A
  1. Exposed to inhaled allergen (antigen) => presented to APC (dendritic cells in lungs)
  2. Carried via MHC II to lymph nodes
  3. Naive T cells differentiate to TH2 cells => Secrete TH2 cytokines
  • IL-4: IgE production
  • IL-5: eosinophill inflammation
  • IL-13: mucus hypersecretion
  1. On repeat exposure to allergen, IgE antibodies bind to mast cells => degranulate and release histamine/chemokines => allergic asthma
69
Q

history and examination for dx of asthma

A
  • recent URTI
  • dyspnoea (painful breathing)
  • cough
  • expiratory wheezes
  • risk factors
  1. FHx
  2. allergens
  3. atopic Hx
  4. nasal polyposis
70
Q

investigations for dx of asthma

A

FEV1/FVC ratio
primary diagnostic test
<80% of predicted

PEFR (peak expiratory flow rate)
- consider long term if moderate/severe persistent asthma, severe exacerbations, or worsening asthma

CXR

  • normal or hyper inflated
  • may show signs of infection in acute exacerbation

FBC

  • normal/raised eosinophils
  • neutrophilia
71
Q

How to classify asthma

A

Non severe

  • Peak expiratory flow 50-75% of normal
  • no respiratory distress signs

Severe (CHEST)

  • Peak expiratory flow 30-50% of normal
  • Respiratory distress (RR >25, hypotension, tachycardia >110bpm)
  • C- cyanosis
  • H- hypotension
  • E-exhaustion /can’t speal full sentences in one breath
  • S- silent chest (poor inspiratory effort, normal PCO2)
  • T-tachy/brady arrythmias
72
Q

Management for acute asthma exacerbation

A

severe asthma (EMERGENCY)

  1. call for help => ITU (high flow oxygen/ ventillation)
  2. Oxygen (>98%)
  3. Bronchodilators (salbutomol +/- ipatropium)
  4. Steroids (oral prednisilone/ IV hydrocortisone)
  5. RE-ASSESS

non-severe asthma

  1. oxygen (>98%)
  2. bronchodilators- salbutamol +/- ipatromium +/- IV magnesium
  3. steroids (prednisilone/ hydrocortisone)
  4. Reassess and discharge if PEF >75%
  5. Long term ICS and TAME (technique inhaler, avoid triggers, monitor PEF, educate)
73
Q

management of exercise induced bronchoconstriction in asthma (acute)

A
  1. SABA (salbutamol) 5-20 mins before asthma
  2. if uncontrolled => inhaled anticholinergics/ mast cell stabilising agents

regular ICS therapy significantly reduces severity of exercise induced bronchoconstriction

74
Q

management plan for chronic asthma

A

newly diagnosed/infrequent symptoms = SABA

chronic:

  1. low dose ICS (fluticasone)
  2. low dose ICS + LTRA (montelukast)
  3. add LABA (salmeterol) (if LTRA not effective stop it)
  4. if uncontrolled, offer maintenance and reliever therapy (MART) combination therapy
    = ICS + fast acting LABA
  5. increase to moderate ICS dose
  6. Specialist therapies
75
Q

examples of asthma drugs + side effects

A

Acute (15-20mins)

  • SABA- salbutamol (palpitations, tachycardia, hypokalemia)
  • anticholinergics (SAMA- ipatropium bromide)

Chronic

  • ICS- fluticasone (sore throat, hoarse voice, mood swings)
  • LABA- salmeterol
  • LAMA- tiotropium
  • LTRA- montelukast (nausea, fever, diarrhoea, headaches, mood swings)
76
Q

Define COPD

A

Chronic, progressive lung disorder characterised with irreversible airflow obstruction

  • chronic bronchitis- chronic cough/ sputum production >3 months
  • emphysema
77
Q

Causes of COPD

A
  • smoking- shorter/less mobile cillia.
  • environmental toxins (dust, NO)
  • a-1 antitrypsin (protease inhibitor) deficiency -younger patients
78
Q

Pathophysiology of COPD

A
  • chronic bronchitis- due to irritants causing hyperplasia of bronchial mucous glands/ goblet cells => mucus hypersecretion (blocked airway)
  • emphysema - enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls.
79
Q

Presenting symptoms of COPD

A
  • chronic cough
  • sputum production
  • breathlessness
  • wheeze
  • reduced exercise tolerance
  • SHx: smoker
80
Q

Examination signs of COPD

A

inspection

  • peripheral cyanosis
  • asterixis/ bounding pulse (CO2 retention)
  • pursed lip breathing
  • barrel chest

palpation

  • bilateral reduced chest expansion

percussion

  • hyper-resonant chest
  • loss of liver/cardiac dullness

auscultation

  • quiet breath sounds
  • wheeze
  • crepitations
  • prolonged expiration
  • rhonchi- rattling continuous low breath sounds (like SNORING)
81
Q

Investigations for COPD

A
  • Bloods (FBC- increased Hb-secondary polycythemia)
  • ABG- show hypoxia/hypercapnia)
  • CXR- hyperinflation, elongated cardiac silhouette
  • Spirometry- reduced FEV1:FVC, increased lung volume
  • ECG + echo - check for cor pulmonale
  • Sputum + blood cultures (exclude infective causes)
  • Legionella/ pneumococci - urinalysis output
  • a1 antitrypsin levels
82
Q

FEV1:FVC ratio in COPD

A

Obstruction = partially blocked airway (reduced FEV1: FVC ratio <70%)

FEV1- how much air you breathe out in 1s FVC- breathe out as much as possible (minus residual lung volume) FEV1:FVC ratio

83
Q

Late signs of COPD

A
  • right sided HF (cor pulmonale)
  • raised JVP
  • ankle oedema
  • right ventricular heave
84
Q

How to classify COPD

A
  • GOLD grading
85
Q

Management of acute COPD exacerbation

A
  • Oxygen - venturi mask (88-92% O2)
  • Steroids- reduce inflammation
  • Nebulisers- bronchodilator

=> WORSE= ventilator

86
Q

Management of chronic COPD

A
  1. SABA/ SAMA
  2. if FEV1 >50% => LABA/ LAMA
  3. if FEV1 <50% => LABA + inhaled corticosteroids

Lifestyle

  • stop smoking
  • exercise
  • vaccines (flu, pneumococcal)
  • pulmonary rehabilitation
  • inhaler therapy
  • oxygen therapy

Stopped smoking => home oxygen

87
Q

Complications of COPD

A
  • cor pulmonale
  • respiratory failure
  • pulmonary hypertension
  • secondary polycythaemia
  • pneumothorax (bullae rupture)
  • infections
88
Q

What are pink puffers and blue bloaters?

A

pink puffers = body not used to high CO2 - heavy pursed lip breathing- high energy expenditure low BMI

blue bloaters BRONCHITIS= mucus hypersecretion => obstruction => high CO2 retention cyanosis => can’t do vigorous exercise => high BMI

89
Q

Why should you not over oxygenate COPD patients?

A

V/q matching

  1. Giving high Oxygen => accumulates in lungs even in useless dead space where there is more CO2
  2. Hb prefers CO2 > oxygen
  3. So still hypoxic => resp acidosis + type 2 resp failure
90
Q

define pneumonia

A

Upper respiratory tract infection with fever and productive cough

  • Community acquired (CAP) or hospital acquired
  1. bronchopneumonia - AIRWAY transmission
  2. lobar pneumonia- blood transmission
91
Q

common causative organisms of pneumonia

A
  • Strep. pneumoniae (MOST COMMON)- gram+ve cocci
  • Haemophilius influenzae- gram -ve
  • Moraxella Cattarharlis

Less common:

  • Mycoplasma
  • Legionella
92
Q

Presenting symptoms of pneumonia

A
  • productive cough
  • yellow/green sputum production
  • fever + chills
  • breathlessness
  • aches (mylagia)
  • dyspnoea
  • pleuritic chest pain
  • risk factors
93
Q

Risk factors for pneumonia (ask in Hx)

A

HPC:

  • older age

PMHx

  • chronic lung conditions (COPD, asthma, bronchitis)
  • diabetes
  • CHD

SHx

  • smoker
  • XS alcohol
  • home/work life - contact with young children
  • home life- In a nursing home
94
Q

Examination signs of pneumonia

A
  • Percussion- dull sounds, increased vocal fremitus
  • Auscultation- coarse crackles, wheeze
95
Q

Investigations for pneumonia

A

Bedside:

  • sputum culture

Bloods:

  • FBC- raised WCC
  • U&Es - raised urea >7mmol/L
  • CRP- >100mg/L
  • ABG- hypoxia
  • LFTs- abnormal in legionella infection
  • blood culture

Imaging

  • CXR (DIAGNOSTIC)
96
Q

How to assess severity of pneumonia?

A

CURB-65 (for Hospital acquired)

  • confusion AMST <8
  • Urea
  • resp rate >30
  • Blood pressure SBP<90
  • >65

CRB-65 (for community acquired)

97
Q

Management of pneumonia

A

0 CURB-65 (in community)

  • oral empirical antibiotics (amoxicillin/ clarithromycin if allergic)

1-2 CURB-65 (community/hospital referral)

  • oral antibiotics
  • oxygen (>98%)
  • Check for SEPSIS

3-4 CURB-65 (hospital)

  • urgent hospital referral
  • immediate IV antibiotics (amoxicllin)
  • Check for SEPSIS
98
Q

prognosis + complications of pneumonia

A
  • 5-15% mortality rate
  • 12% recurrence

Complications

  • Sepsis
  • ARDS
  • pleural effusion
  • Heart failure
99
Q

define TB

A
  • it’s an infection caused by mycobacterium tuberculosis bacteria
  • spread by droplet transmission (coughing/sneezing)
  • NOTIFIABLE disease
  1. active TB (symptomatic)
  2. latent TB (asymptomatic + carrier)
  3. extrapulmonary TB (brain, heart, bones, joints, abdo, genitourinary, lymphatic)
100
Q

pathophysiology of TB

A
  • bacteria reside in macrophages and travel to regional lymph nodes/ lungs
  • form a granuloma
101
Q

risk factors for TB

A
  • foreign endemic countries (India, pakistan, bangladesh, somalia)
  • co-morbid conditions (HIV, DM, CKD)
  • immunosuppressive drugs (corticosteroids, infliximab, chemotherapy)
  • close contact
  • previous TB
  • <5 age
  • at risk groups (homeless, prisons, hostels, poorer people)
  • smokers, alcoholics, drug users
102
Q

presenting symptoms of TB (respiratory)

A
  • productive cough
  • breathlessness
  • haemoptysis
  • FLAWS (fever, malaise, weight loss, anorexia, night sweats)
103
Q

symptoms of extrapulmonary TB

A
  • lymphadenopathy ( lymphatic TB)
  • bone/joint pain (joint/spinal TB)
  • headache, irritability, vomiting, cranial nerve abnormalities (TB meningitis)
  • breathlessness, chest pain, ankle swelling (pericarditis TB)
  • sterile pyuria (renal TB)
  • abdo pain, constipation, bowel obstruction (gastric TB)
  • skin lesions, erythema nodosum (cutaneous TB)
104
Q

investigations for TB

A

Asymptomatic (latent TB)

  1. Tuberculin skin test
  2. Interferon gamma assay

*if tests are positve => CXR

Symptomatic (active TB)

  • x3 sputum samples MC&S- acid-fast bacilli smear (Ziel-Nielson stain)
  • Bloods: FBC (high WCC, anaemia), CRP, ABG, HIV
  • CXR (nodular opacities, pleural effusion, bihilar lymphadenopathy)
105
Q

management for TB (RIPE)

A
  • Rifampicin (red secretions)
  • Isoniazid (peripheral neuropathy)
  • Pyrazinamide (gout)
  • Ethambutol (eye-red-green colour blindness)

if multi-drug resistant consider surgery (wedge/lobar resection)

NOTIFIABLE DISEASE

  • identify and check on close contacts
106
Q

define Influenza

A

winter flu associated with upper and lower respiratory tract infection symptoms

  • Influenza A/B
  • usually self resolving (1/2 weeks- anti-virals speed up recovery by 2 days)
  • annual flu vaccine (preventatitve)
107
Q

presenting symptoms of influenza

A
  • fever
  • cough
  • runny nose (rhinorrhoea)
  • chills
  • headaches
  • mylagia (muscle ache)
  • risk factors
  • Hx- vaccinated ?
108
Q

risk factors for influenza

A
  • <5 or >65
  • pregnant women
  • healthcare workers
  • immunocompromised (HIV)
  • Diabetics
  • CKD
  • unvaccinated
  • winter season
109
Q

investigations for influenza

A
  • usually clinical diagnosis

can consider viral culture/serology, reverse transcriptase PCR, CXR- exclude pneumonia

110
Q

management for influenza

A

Conservative:

  • rest
  • warm drinks
  • anti-pyretics/ analgesia- symptom relief

,Medical:

  • if complicated/severe disease => anti-viral
  • if bacterial infection/ ear infection => broadspectrum antibiotics (amoxicillin)

Post-disease

  • Vaccine
111
Q

complications of influenza

A
  • bacterial pneumonia
  • viral pneumonia
  • otitis media
  • meningitis/ encephalitis
112
Q

define pulmonary hypertension

A

increase in pulmonary vascular resistance in the pulmonary arteries leading to right ventricular failure and death

113
Q

presenting symptoms of pulmonary hypertension

A
  • exertional dyspnoea
  • fatigue
  • peripheral oedema
  • cyanosis
  • Risk factors: family Hx, female
114
Q

signs of pulmonary hypertension

A
  • pan-systolic murmur (tricuspid regurgitation)
  • loud pulmonary component of S2
115
Q

Investigations for pulmonary hypertension

A

Bloods: (check for cause)

  • FBC- haemoglobinopathy
  • LFTs - portal hypertension/liver disease
  • BNP (right ventricular dysfunction)

Imaging:

  • CXR
  • Transthoracic echocardiogram
    *
116
Q

define pulmonary fibrosis

A

thickening and scarring of lung tissue => stiff lungs so they don’t work properly and get more pregoressive SOB

117
Q

causes of pulmonary fibrosis

A
  • toxins - asbestos, silica, coal, grain, metal
  • radiation
  • medical conditions - dermatomyositosis, SLE, RA, polymyositosis
  • medication- chemo, amiodarone, antibiotics
118
Q

risk factors for pulmonary fibross

A
  • smoking
  • mining,farming,construction WORK
  • cancer treatment
  • family Hx
119
Q

presenting symptoms + signs of pulmonary fibrosis

A

symptoms:

  • shortness of breath/ dyspnoea on exertion
  • dry cough
  • fatigue
  • weight loss
  • muscle + joint aches

signs:

  • finger clubbing
  • bibasal crackles
120
Q

investigations for pulmonary fibrosis

A
  • Pulse ox
  • exercise stress test
  • lung function tests/ spirometry
  • ABG - check for resp failure

Imaging:

  • CXR
  • CT thorax- shows lung scarring
  • Echo
121
Q

management for pulmonary fibrosis

A
  • Usually conservative
  • Pulmonary rehabillitation
  • oxygen
  • symptomatic relief - benzo’s/ opioids
122
Q

complications of pulmonary fibrosis

A
  • respiratory failure
  • pulmonary hypertension => cor pulmonale
  • lung cancer
  • PE/PTX/ collapsed lung
123
Q

define lower respiratory tract infection

A
124
Q

define COVID-19

A
  • variant of SARS-COV-2 virus
  • type of betacoronavirus
125
Q

high risk groups for COVID-19

A

High

  • cancer patients (leukaemia)
  • undergoing chemo
  • surgery
  • on immunosuppressant drugs (corticosteroids)
  • chronic lung conditons (CF)
  • HIV/ sickle cell

Medium

  • diabetics
  • asthma, COPD, bronchitis
  • heart failure
  • CKD
  • liver failure
  • pregnancy
126
Q

symptoms of COVID-19

A
  • range from asymptomatic => mild resp. infection => pneumonia

common symptoms

  • fever
  • new coninuous dry cough
  • loss of smell/taste
  • SOB
  • fatigue
  • loss of appeitie
  • other - rashes, headches, muscle pains, runny nose

delta variant common symptoms

  • runny nose
  • headache
  • sore throat
127
Q

investigations for COVID-19

A
  • symptomatic / contact with positive person => PCR test (antibody test)
  • asymptomatic => lateral flow tests
128
Q

management for COVID-19

A
  • self-isolate for 10 days
  • admit to hospital if
  1. pneumonia
  2. influenza like illness (>37.8 temp + SOB/nasal dishcarge, hoarseness)
  3. acute respiratory distress syndrome
129
Q

complications of COVID-19

A
  • Long-covid -fever, fatigue, pain, SOB, chest pain, palpitations, cough, nausea, diarrhoea, muscle pain, tinitus,dizziness, delerium, depression

Investigate for severe complications

  • FBC
  • LFTs, U&Es
  • CRP
  • HbA1c
  • BNP

Management

  • urgent referral - hypoxemia, severe lung disease, cardiac chest pain, inflammatory syndrome, suicidal thoughts
  • social prescribing
  • manage symptoms

Year 3 (27 decks)

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