Respiratory Flashcards
1
Q
ASTHMA
What is the pathophysiology of asthma?
A
- Airway narrowing + obstruction due to bronchial muscle contraction as well as inflammation caused by mast cell degranulation + increased mucus production
2
Q
ASTHMA
What are the three main characteristics of asthma?
A
- Airflow limitation (reversible)
- Airway hyperresponsiveness to various stimuli
- Bronchial inflammation
3
Q
ASTHMA
What three histopathological changes are seen in asthma?
A
- Basement membrane thickening
- Epithelium metaplasia (increased goblet cells)
- Increase in inflammatory gene expression on many cell types
4
Q
ASTHMA
What 2 broad aetiological categories can asthma be split into?
A
- Allergic (extrinsic, eosinophilic) = T1 IgE mast cell mediated hypersensitivity reaction caused by allergens, atopy (eczema, hayfever)
- Non-allergic (intrinsic, non-eosinophilic) = idiopathic but triggers
5
Q
ASTHMA
What are some triggers and risk factors for asthma?
A
- Smoking, allergens, exercise, damp, NSAIDs, B-blockers
- LBW, child exposure to smoke, PMH/FHx atopy, air pollution
6
Q
ASTHMA
What is the clinical presentation of asthma?
A
- Episodic Sx with diurnal variability (worse night/early morning)
- Dry cough with wheeze, dyspnoea + chest tightness
- Widespread polyphonic wheeze on auscultation
7
Q
ASTHMA
What first-line lung function tests can be used to help diagnose asthma?
A
- Fractional exhaled nitric oxide (FeNO)
- Spirometry
(- Peak expiratory flow rate variability)
8
Q
ASTHMA
What results show inflamed airways for FeNO testing?
A
- > 40ppb adults
- >35ppb paeds
9
Q
ASTHMA
What would spirometry show in asthma?
A
- Obstructive pattern = FEV1 <80%, FEV1/FVC <0.7
- Beta-2-agonist reversibility with FEV1 ≥12% improvement
10
Q
ASTHMA
What would PEFR show in asthma?
A
- Diurnal variation >20% on ≥3d/w
11
Q
ASTHMA
What other investigations may you consider in asthma?
A
- Skin prick tests for atopy
- Serial PEFR at work/away if occupational (usually due to isocyanates = paints + flour)
- CXR = ?hyperinflation
12
Q
ASTHMA
What lifestyle advice would you give to someone with asthma?
A
- Correct inhaler technique
- Avoid triggers + smoking
- Monitor peak flow
- Yearly flu jab + asthma r/v
- Asthma self-management programme
13
Q
ASTHMA
What are the 5 main drugs used in the treatment of asthma?
A
- Short-acting beta-2-adrenergic receptor agonists (SABA, salbutamol)
- Inhaled corticosteroids (ICS, beclometasone, bumetanide)
- Long-acting beta-2-adrenergic receptor agonists (LABA, salmeterol)
- Leukotriene receptor antagonists (LTRA, montelukast)
- Theophylline
14
Q
ASTHMA
What is the mechanism of action of…
i) SABA/LABA?
ii) ICS?
iii) LTRA?
iv) theophylline?
A
i) Adrenaline acts on airway smooth muscle to dilate bronchioles (short/long acting)
ii) Reduced inflammation + reactivity of airways
iii) Blocks leukotrienes which are produced by immune system + cause inflammation, bronchoconstriction + mucous secretion
iv) Relaxes bronchial smooth muscle and reduces inflammation
15
Q
ASTHMA
What is an important drug safety aspect of theophylline?
A
- Narrow therapeutic window + toxic in excess so monitor plasma theophylline levels 5d after starting and 3d after dose changes
16
Q
ASTHMA
Adult and 5–16y/o asthma management: what are the first 4 steps?
A
- Step 1 = SABA (if newly-diagnosed but Sx ≥3/w or night-waking STEP 2)
- Step 2 = add low-dose ICS
- Step 3 = add LTRA
- Step 4 = add LABA (continue LTRA depending on patient’s response)
17
Q
ASTHMA
Adult and 5–16y/o asthma management: what are steps 5–7?
A
- Step 5 = SABA ± LTRA plus switch ICS + LABA for low-dose ICS MART (Fostair = beclo/form, Symbicort = buden/form)
- Step 5 = SABA ± LTRA plus medium-dose ICS MART (or fixed dose moderate-dose ICS + separate LABA)
- Step 7 = SABA ±LTRA plus high-dose ICS (if not on MART), trial PO theophylline, specialist input
18
Q
ASTHMA
Paediatric <5y/o management: what are steps 1 and 2?
A
- Step 1 = SABA
- Step 2 = add 8w trial of moderate-dose inhaled ICS
19
Q
ASTHMA
After the 8w trial how would you manage their response?
A
- No response = stop + consider alternative Dx
- Sx resolved but reoccurred <4w = restart ICS at low-dose
- Sx resolved but reoccurred >4w = repeat 8w trial
20
Q
ASTHMA
Paediatric <5y/o management: what are steps 3 and 4?
A
- Step 3 = SABA + low-dose ICS plus LTRA
- Step 4 = stop LTRA and refer to paeds asthma specialist
21
Q
ASTHMA
How does an acute asthma attack present?
A
- Worsening dyspnoea, wheeze + cough not responding to SABA
- Use of accessory muscles
22
Q
ASTHMA
What constitutes a moderate asthma exacerbation?
A
- PEFR 50–75% predicted
- RR <25/min
- HR <110bpm
- Speech normal
23
Q
ASTHMA
What constitutes a severe asthma exacerbation?
A
- PEFR 33–50% predicted
- RR ≥25/min (>30 if >5y/o, >40 if <5y/o)
- HR ≥110 (>125 if >5y/o, >140 if <5y/o)
- Unable to complete full sentences
24
Q
ASTHMA
What constitutes a life-threatening asthma exacerbation?
A
- PEFR <33% predicted
- SpO2 <92%
- Silent chest (airways tight so no air entry) + cyanosis
- HD unstable
- Exhaustion/altered GCS
- ABG = normal CO2
25
ASTHMA
| What investigations would you do in an acute asthma exacerbation?
- Bloods = FBC, U&E, CRP
- ABG if SpO2 <92%
- CXR to exclude differentials
26
ASTHMA
| How might an ABG change during an acute asthma exacerbation?
- Initially respiratory alkalosis due to tachypnoea dropping CO2
- Normal pCO2 or hypoxia is concerning sign as indicates exhaustion
- Respiratory acidosis due to high CO2 is very bad sign = near-fatal asthma
27
ASTHMA
| What is the management of an acute asthma exacerbation?
O SHIT ME –
- Oxygen (SpO2 94–98%), 15L NRB and titrate down
- Salbutamol 5mg spacer or neb (oxygen driven, IV if no response)
- Hydrocortisone 100mg IV or PO pred 40–50mg for 5d
- Ipratropium bromide 0.5mg neb (severe/life-threatening or not responding to SABA/steroid)
- Theophylline IV (senior)
- Mag sulf 2g IV (senior) this before theophylline
- Escalate early > ICU
28
ASTHMA
| What are the discharge criteria following an asthma exacerbation?
- Stable on d/c meds (no nebs or oxygen) for 12–24h
- Inhaler technique checked + recorded
- PEFR >75% predicted
29
COPD
What is COPD?
What is it made up of?
- Non-reversible, progressive deterioration in airflow through the lungs caused by damage to lung tissue causing airway obstruction making it more difficult to ventilate the lungs making them prone to developing infections
- Chronic bronchitis (blue bloaters) and emphysema (pink puffers)
30
COPD
What is...
i) chronic bronchitis?
ii) emphysema?
i) Hypertrophy + hyperplasia of mucus glands in bronchi = V/Q mismatch due to bronchoconstriction so cyanosis but no hyperventilation, rely on hypoxic drive
ii) Enlargement of air spaces + destruction of alveolar walls so air trapping post exhalation = inability to oxygenate so hyperventilation but no cyanosis
31
COPD
| What are the causes of COPD?
- Smoking = major contributor
| - Early-onset emphysema in alpha-1-antitrypsin deficiency due to increase in proteases which damage lung tissue
32
COPD
| What are the symptoms and signs of COPD?
- Chronic cough, sputum (often white), dyspnoea
- Tachypnoea, pursed-lip breathing, cachexia, expiratory wheeze, accessory muscle use, hyperinflated barrel chest (reduced cricosternal distance)
33
COPD
| What initial investigations might you do in COPD?
- ECG = P pulmonale (RA hypertrophy) + RVH if cor pulmonale
- FBC (polycythaemia if chronic hypoxia)
- A1AT levels
- ABG (high bicarb indicates chronic CO2 retainer)
- CXR = hyperinflated chest (>6 ant. ribs), flat hemidiaphragm, bullae
34
COPD
What diagnostic investigation would you do in COPD?
How is it classified?
- Spirometry = obstructive with no reversibility (FEV1 <80%, FEV1/FVC <70%)
All have FEV1/FVC <70% –
- Stage 1 mild = Sx for diagnosis as FEV1≥80%
- Stage 2 moderate = FEV1 50–79%
- Stage 3 severe = FEV1 30–49
- Stage 4 very severe = FEV1 <30%
35
COPD
What are bullae?
How may they present?
- Air spaces in lung due to alveolar damage
| - If large can mimic pneumothorax presenting as lucency without a visible wall
36
COPD
| What is the lifestyle management of COPD?
- Smoking cessation #1
- Yearly flu + one off PCV
- Pulmonary rehab (exercise, nutrition, breathing exercises, education)
37
COPD
| What is the mechanism of action of short/long-acting muscarinic antagonists and give examples?
- Block ACh receptors which are usually stimulated by PSNS causing bronchial smooth muscle contraction + bronchoconstriction
- Short = ipratropium bromide
- Long = tiotropium bromide (Spiriva)
38
COPD
What is the first step in COPD management?
What is considered in step 2?
- SABA or SAMA PRN
- Features suggestive of steroid responsiveness = previous atopy Dx, eosinophilia, reduced FEV1 or diurnal FEV1 variation
39
COPD
| What is the further management of COPD in someone with no steroid responsive features?
- LABA + LAMA (Ultibro) (if on SAMA swap to SABA PRN)
| - If still breathless or exacerbations then triple therapy with LABA + LAMA + ICS (Trimbow)
40
COPD
| What is the further management of COPD in someone with steroid responsive features?
- LABA + ICS (Fostair)
- If still breathless or exacerbations then triple therapy with LABA + LAMA + ICS (Trimbow) (if on SAMA swap to SABA PRN)
41
COPD
If triple therapy fails, what else might be considered?
What other interventions may be considered?
- PO theophylline, mucolytics like carbocisteine, specialist input
- Long-term oxygen therapy (LTOT)
- Lung volume reduction surgery or transplant if severe in select
42
COPD
| What is the criteria for LTOT?
- 2x ABGs 3w apart showing PaO2 <7.3 or 7.3–8 with 1 of: nocturnal hypoxia, polycythaemia, peripheral oedema or pulmonary HTN
- Non-smokers only due to fire hazard
43
COPD
How does an acute exacerbation of COPD present?
What are the common causes?
- Increased dyspnoea, cough + wheeze ± purulent sputum
| - Haemophilus influenzae #1, strep. pneumoniae, Moraxella catarrhalis, viral
44
COPD
| What investigations would you do in someone with an acute COPD exacerbation?
- FBC, U&E, CRP, ABG, blood cultures if septic
| - Sputum MC&S, ECG, CXR
45
COPD
| What is the initial management of an acute COPD exacerbation?
ABCDE
- Oxygen (15L NRB then titrate using venturi 28–40) aim for 88–92%
- Increase bronchodilator use ± nebs (salbutamol 5mg 4h, ipratropium 0.5mg 6h)
- PO pred 30mg OD 5d or IV hydrocort 200mg if severe
- PO amox/doxy/clari if sputum purulent or clinical signs of pneumonia
- Chest physio to aid sputum clearance
46
COPD
| If the initial acute COPD management fails, what can be done?
- Escalate to NIV ± intubation with ICU support
- CPAP = T1RF and pulmonary oedema
- BiPAP = T2RF
47
LUNG CANCER
What are the 2 main types of lung cancer? Which is more common?
What are some risk factors?
- Non-small cell lung carcinoma (majority)
- Small cell lung carcinoma
- Smoking, occupational (asbestos, silica), HIV, radiation
48
LUNG CANCER
| What are the three subtypes of NSCLC? What are some features of each?
- Adenocarcinoma (#1) = most common type in non-smokers but most pts smokers, peripheral
- Squamous = smokers, central, cavitates, poor prognosis
- Large cell = peripheral, large, poorly differentiated
49
LUNG CANCER
| What specific sequelae can adenocarcinomas and squamous cell carcinomas lead to?
- Adeno = gynaecomastia
| - Squamous = high Ca2+ from ectopic PTH-rP = primary hyperparathyroidism and hypertrophic pulmonary osteoarthropathy
50
LUNG CANCER
| What are some features of SCLC?
- Almost always smokers, central, early mets, causes paraneoplastic syndromes and SVC obstruction, worst prognosis
51
LUNG CANCER
| What are some SCLC paraneoplastic syndromes?
- ADH > SIADH
- ACTH = Cushing's + also ?bilateral adrenal hyperplasia with high cortisol leading to hypokalaemic alkalosis
- Lambert-Eaton myasthenic syndrome
52
LUNG CANCER
| What is the referral criteria for lung cancer?
≥40y and ≥2 unexplained Sx in a non-smoker or ≥1 smoker = urgent 2w CXR
- SOB, cough, chest pain
- Fatigue, weight loss, appetite loss
CXR ?lung cancer or haemoptysis in ≥40y = urgent 2ww appt
53
LUNG CANCER
What signs are concerning for lung cancer?
What is the referral criteria?
Consider 2w urgent CXR if ≥40y with any of:
- Persistent or recurrent chest infection
- Finger clubbing
- Supraclavicular or persistent cervical lymphadenopathy
- Fixed monophonic wheeze
- Thrombocytosis on FBC
54
LUNG CANCER
What is the first-line investigation used in lung cancer?
What might it show?
- CXR
- Peripheral/hilar opacity indicating nodule
- Pleural effusion due to inflammatory reaction
- Pneumothorax or atelectasis (collapse of lung or lobe)
55
LUNG CANCER
| What further investigations are required to diagnose lung cancer?
- CT CAP (staging)
- Biopsy for cytology either via bronchoscopy (EBUS) if central or CT guided biopsy with fine needle aspiration if peripheral
- PET scan
56
LUNG CANCER
| What are some potential complications due to lung cancer?
- L recurrent laryngeal nerve palsy = hoarse voice
- Phrenic nerve palsy = diaphragm weakness with SOB
- Brachial plexus = shoulder pain
- Sympathetic ganglion = Horner's syndrome (anhidrosis, miosis, ptosis in apical Pancoast tumours)
- Mets to bone, brain, liver
- SVCO
57
LUNG CANCER
| How does SVCO present?
- Oncological emergency = SOB, swelling of face, neck + arms, visual disturbance and dilated veins
- Pemberton's test = lift arms = facial plethora and cyanosis
58
LUNG CANCER
| What is the management of SVCO?
- STAT PO dexamethasone
| - ?stenting or chemo/radiotherapy
59
LUNG CANCER
| What is the management of NSCLC?
- Lobectomy first-line if isolated
- Curative radiotherapy if stage I–II
- Chemotherapy if stage III–IV to control disease + improve QOL
60
LUNG CANCER
| What is the management of SCLC?
- Often just palliative chemotherapy
61
PNEUMONIA
| What are the three main types of pneumonia?
- CAP = outside hospital
- HAP = >48h after admission
- Aspiration = acute aspiration of gastric contents into lungs, seen in neuro deficit (CVA, MS, MND), LOC, intoxication + tracheostomy
62
PNEUMONIA
| What are the common causes of CAP?
- Strep pneumoniae #1
- Haemophilus influenzae (COPD)
- Staph aureus (commonly after influenza)
63
PNEUMONIA
| What are the common causes of HAP?
- Pseudomonas aeruginosa
- Staph aureus
- Gram -ve enterobacteria
- Klebsiella pneumoniae
64
PNEUMONIA
| What are some unique features of klebsiella pneumonia?
- Seen in alcoholics
- Red-currant sputum
- Upper lobes affected giving cavitating pneumonia
65
PNEUMONIA
| What are the atypical pneumonias?
Legions of psittaci MCQs –
- Legions = legionella pneumophila
- Psittaci = chlamydia psittaci
- M = mycoplasma pneumoniae
- C = chlamydophila pneumoniae
- Q = Q fever (Coxiella burnetti)
66
PNEUMONIA
| What are the features of legionella pneumophila?
- From infected water supplies + aircon
| - Dry cough, relative bradycardia, confusion, lymphopaenia, hyponatraemia + deranged LFTs
67
PNEUMONIA
What are the features of...
i) chlamydia psittaci?
ii) Q fever?
i) Infected birds, flu-like Sx, splenomegaly
| ii) animal + their bodily fluids exposure
68
PNEUMONIA
What are the features of mycoplasma pneumoniae?
What are some complications?
- Erythema multiforme, dry cough, flu-like Sx, neuro Sx in young
- Complications = cold agglutins IgM haemolytic anaemia, neuro (GBS, encephalitis), peri/myocarditis, bullous myringitis
69
PNEUMONIA
| What fungal cause of pneumonia is there?
- Pneumocystis jiroveci seen in immunocompromised
70
PNEUMONIA
| What are the symptoms and signs of pneumonia?
- Fever, SOB, cough with purulent sputum (dry in atypicals), haemoptysis + pleuritic CP
- Pyrexia, tachypnoea, tachycardia, focal coarse creps, dull to percuss, bronchial breathing
71
PNEUMONIA
| What initial risk tool would you calculate in someone with suspected pneumonia?
CURB-65 –
- Confusion
- Urea >7mmol/L
- RR >30
- BP <90/60
- ≥65 years old
72
PNEUMONIA
| What investigations would you do in pneumonia?
- Bloods = FBC (neutrophilia, raised WCC), U&E, LFT, CRP, cultures
- Sputum MC&S, mycoplasma and COVID-19 PCRs
- Pneumococcal + legionella urinary antigen tests
- CXR
73
PNEUMONIA
What might a CXR show in pneumonia?
What would you expect in aspiration pneumonia?
- Lobar, multilobar, cavitation or pleural effusions
| - R middle/lower lobe consolidation due to R bronchus being more vertical
74
PNEUMONIA
| What are some complications of pneumonia?
- Pleural effusion + empyema
- Lung abscess
- Pneumothorax
- Sepsis
75
PNEUMONIA
How would empyema present?
How do you manage it?
- WCC/CRP/temp won't settle after Abx, foul smelling sputum
| - Chest drain
76
PNEUMONIA
What is the initial management of pneumonia?
What follow-up is required?
- Oxygen to maintain SpO2 >94%
- Abx
- Follow-up appt + CXR in 6w
77
PNEUMONIA
What Abx are given for...
i) CURB 0-1?
ii) CURB 2?
iii) CURB ≥3?
iv) HAP?
v) aspiration?
vi) atypicals?
i) PO amox in community
ii) PO amox + clari in hospital
iii) IV co-amox + clari ?ICU
iv) Not severe = PO co-amox, severe = IV piperacillin with tazobactam
v) IV metro + cephalosporin
vi) Macrolides, fluoroquines (levofloxacin) or doxy
78
PNEUMOTHORAX
What is a pneumothorax?
What are the three main types of pneumothorax?
- Air within the pleural space
| - Spontaneous, traumatic and tension
79
PNEUMOTHORAX
| How is spontaneous pneumothorax subdivided?
- Primary (no underlying pathology) = tall, thin, young male, smoker
- Secondary = COPD, asthma, Marfan's, TB, pneumonia, CF, cancer
80
PNEUMOTHORAX
| How is traumatic pneumothorax subdivided?
- Iatrogenic = insertion of central line, pericardiocentesis or positive pressure ventilation
- Non-iatrogenic = penetrating trauma or blunt trauma with rib #
81
PNEUMOTHORAX
| What is a tension pneumothorax?
- Trauma creates a one-way valve which allows pressure in the thorax to rise
82
PNEUMOTHORAX
| What is the clinical presentation of pneumothorax?
- Sudden onset SOB + pleuritic chest pain
- Reduced chest expansion
- Hyperresonance to percuss
- Reduced breath sounds
83
PNEUMOTHORAX
| How does a tension pneumothorax present?
The same plus
- Contralateral tracheal deviation
- Systemic features = shock, distended neck veins
84
PNEUMOTHORAX
| What investigation would you do in pneumothorax and what would you expect to see?
- CXR
| - Lung markings don't extend all the way to the periphery and pleural line
85
PNEUMOTHORAX
| What is the management of a tension pneumothorax?
- ABCDE, 15L oxygen via NRB
- Urgent 14G cannula needle decompression in 2nd intercostal space mid-clavicular line prior to Ix (aim for above 3rd rib)
- Chest drain insertion
86
PNEUMOTHORAX
| What forms the safe triangle for chest drain insertion?
- 5th intercostal space
- Base of axilla
- Lateral edge of pectoralis major
- Lateral edge of latissimus dorsi
87
PNEUMOTHORAX
| What is the management of primary pneumothorax?
- Rim of air <2cm + not SOB = ?d/c, OP review in 2–4w
| - Rim of air >2cm or SOB = needle aspiration > chest drain if fails
88
PNEUMOTHORAX
| What is the management of secondary pneumothorax?
- Rim of air <1cm + not SOB = supplemental oxygen + admit for 24h
- Rim of air 1–2cm + not SOB = needle aspiration > chest drain if fails
- Rim of air >2cm OR SOB = chest drain
89
PNEUMOTHORAX
| How do you manage an iatrogenic pneumothorax?
- Observation, majority resolve and are less likely to recur
| - Aspiration if no resolution
90
PNEUMOTHORAX
| What discharge and post-pneumothorax advice should be given to patients?
- Stop smoking to reduce recurrence
- Fit to fly = 2w after successful drainage if no residual air post CXR
- Scuba diving = permanently avoid unless bilateral surgical pleurectomy + normal lung function + CT chest post-op
91
PLEURAL EFFUSION
What is a pleural effusion?
What are the 2 main categories, how is it quantified and how are they commonly distributed?
- Abnormal buildup of fluid in the pleural cavity
- Transudative, <30g/L protein, often bilateral
- Exudative, >30g/L protein, often unilateral
92
PLEURAL EFFUSION
| What are some transudative causes of pleural effusions?
- #1 = heart failure (increased capillary hydrostatic pressure)
- Reduced capillary oncotic pressure (hypoalbuminaemia) = cirrhosis, nephrotic syndrome, GI malabsorption
- Other = hypothyroidism, Meig's syndrome
93
PLEURAL EFFUSION
| What are some exudative causes of pleural effusions?
- #1 = pneumonia, other infections like TB
- Neoplasia = lung cancer, mesothelioma, mets
- Inflammatory = RA, SLE, acute pancreatitis
- PE
94
PLEURAL EFFUSION
| What are the symptoms and signs of a pleural effusion?
- SOB, reduced exercise tolerance + chest pain
- Stony dull to percuss, reduced/absent breath sounds over effusion ± bronchial breathing at upper border, ipsilateral reduced chest expansion
95
PLEURAL EFFUSION
| What first-line and diagnostic investigations would you do in pleural effusions?
- PA CXR in all patients
- Diagnostic ultrasound-guided pleural aspiration with fluid sent for pH, protein, LDH, glucose, amylase, cytology + microbiology
96
PLEURAL EFFUSION
| What might you see on a CXR in pleural effusion?
- Blunting of costophrenic angles ± meniscus
- Fluid in lung fissures
- White out of one hemifield ± contralateral tracheal deviation if large
97
PLEURAL EFFUSION
| What would you expect in the pleural aspirate in empyema?
- pH <7.2
- Low glucose
- High LDH
98
PLEURAL EFFUSION
In the pleural aspirate, what would you consider if there was...
i) low glucose?
ii) high amylase?
iii) heavy blood staining?
i) RA, TB, malignancy
ii) Pancreatitis
iii) Mesothelioma, PE, TB
99
PLEURAL EFFUSION
| If the protein is equivocal (25–35g/L), what can you do to determine if the effusion is transudative or exudative?
Light's criteria showing exudates likely if ≥1 of:
- Pleural fluid protein ÷ serum protein >0.5
- Pleural fluid LDH ÷ serum LDH >0.6
- Pleural fluid LDH >2/3rd upper limits of normal serum LDH
100
PLEURAL EFFUSION
| How do you manage a pleural effusion?
- ABCDE ± supplemental oxygen and treat underlying cause as may resolve if small
- If aspirate purulent/cloudy, or clear but pH <7.2 with suspected pleural infection = chest tube for drainage
101
PLEURAL EFFUSION
| What is the management of recurrent pleural effusions?
- Pleurodesis = obliteration of pleural space
| - Chemically = tetracycline or bleomycin or surgical = thoracotomy or thoracoscopy
102
TUBERCULOSIS
| What is the pathophysiology of TB?
- Mycobacterium tuberculosis is engulfed by macrophages leading to a caseating granuloma (Ghon focus) which then migrates to the hilar lymph nodes (Ghon complex)
103
TUBERCULOSIS
| What can happen after primary TB?
- Secondary = reactivation of latent TB secondary to immunosuppression
- Miliary = bloodstream disseminated TB > millet-seeds on CXR
104
TUBERCULOSIS
| What are some risk factors for developing TB?
- Ethnic minority groups e.g., sub-Saharan Africa + South Asia
- Homeless + drug + alcohol abuse
- Close contact with infected patient
- Immunosuppression (HIV, cancer, organ transplant)
105
TUBERCULOSIS
What is the general presentation of TB?
Where does it affect most commonly?
Where else can it affect?
- Subacute/chronic night sweats, fever, weight loss + erythema nodosum
- Pulmonary
- CNS, GU, MSK, cardio
106
TUBERCULOSIS
What is the presentation of TB affecting...
i) lungs?
ii) CNS?
iii) GU tract?
iv) MSK system?
v) heart?
i) Chronic cough ± haemoptysis
ii) Headache, meningism + focal neurology
iii) Sterile pyuria, abscesses, epididymo-orchitis
iv) Arthritis, osteomyelitis, Pott's disease of spine
v) Pericardial effusions + constrictive pericarditis
107
TUBERCULOSIS
What investigations can...
i) aid acute diagnosis?
ii) screen for latent TB?
i) CXR and 3x samples of sputum MC&S
| ii) Mantoux 'tuberculin' test and interferon gamma release assays
108
TUBERCULOSIS
What might a CXR show in...
i) primary TB?
ii) post-primary TB?
i) Consolidation, pleural effusion + bilateral hilar lymphadenopathy
ii) Upper lobe cavitation, healing > fibrosis, pleural effusions
109
TUBERCULOSIS
| What would sputum MC&S show in TB?
- Acid fast bacilli
| - Stains red with Ziehl-Neelsen stain on Lowenstein-Jenson culture medium
110
TUBERCULOSIS
What does the Mantoux test show?
Why would you do the interferon gamma release assay?
- >15mm = active TB, 6–15mm = previous exposure (?BCG vs. latent)
- Can confirm latent TB as differentiates from BCG
111
TUBERCULOSIS
How can TB be prevented?
What are the logistical aspects to a TB diagnosis?
- BCG vaccine in high risk neonates (FHx, relatives from countries with high TB rate) + healthcare workers
- Contact tracing and notification of PHE
112
TUBERCULOSIS
What is the medical treatment of...
i) active TB?
ii) latent TB?
iii) directly observed therapy?
i) RIPE = rifampicin 6m, isoniazid 6m (co-prescribe vitamin B6 pyridoxine after puberty as prophylaxis for peripheral neuropathy), pyrazinamide 2m, ethambutol 2m
ii) Isoniazid + vitamin B6 for 6m or 3m isoniazid + vitamin B6 + rifampicin
iii) 3x/w for prisoners, homeless or poorly adherent patients
113
TUBERCULOSIS
| What are some side effects from the medications used in TB?
- Rifampicin = red urine, CYP450 inducer, hepatitis
- Isoniazid 'I'm-so-numb-azid' = peripheral neuropathy, hepatitis
- Pyrazinamide = gout due to hyperuricaemia, rash, arthralgia
- Ethambutol 'eye-thambutol' = optic neuritis, reduced acuity + colour > CHECK VISUAL ACUITY BEFORE
114
BRONCHIECTASIS
| What is bronchiectasis?
- Permanent dilatation of the airways (bronchi + bronchioles) leading to impaired clearance of bronchial secretions, secondary bacterial infection and progressive lung damage due to bronchial inflammation
115
BRONCHIECTASIS
| What is the aetiology of bronchiectasis?
- Post-infective = TB, measles, pertussis, pneumonia
- Congenital = CF, Kartagener's + Young's syndromes
- Bronchial obstruction = cancer, foreign body
- Immune deficiency = hypogammaglobulinaemia
- Allergic bronchopulmonary aspergillosis
116
BRONCHIECTASIS
| What is the clinical presentation of bronchiectasis?
- Chronic cough with purulent sputum (thick, foul-smelling + green)
- Haemoptysis
- Signs = finger clubbing, coarse inspiratory creps + wheeze
117
BRONCHIECTASIS
| What investigations would you do in bronchiectasis?
- Sputum culture
- Spirometry = obstructive (FEV1<80%, FEV1/FVC<70%)
- CXR
- High resolution CT chest = diagnostic
118
BRONCHIECTASIS
What organisms are most commonly isolated in bronchiectasis?
What does the CXR show in bronchiectasis?
What does the HR CT chest show in bronchiectasis?
- H. influenzae #1, also p. aeruginosa + klebsiella spp.
- Thickened bronchial walls + cystic appearance (tramlines + ring shadows)
- Widespread tram-track + signet ring signs
119
BRONCHIECTASIS
| What is the conservative management of bronchiectasis?
- Support groups + patient education
- Smoking cessation
- Chest physio for sputum clearance
- Annual flu + one-off pneumococcal vaccine
120
BRONCHIECTASIS
What is the medical management of bronchiectasis?
What is the surgical management of bronchiectasis?
- Abx for exacerbations + long-term rotating Abx in severe cases
- Bronchodilators (salbutamol) if SOB + wheeze
- Mucolytic carbocisteine to reduce sputum viscosity
- Surgical excision if localised disease or severe haemoptysis control
121
INTERSTITIAL LUNG DISEASE
| What causes fibrosis predominately affecting the upper zones?
CHARTS –
- Coal worker's pneumoconiosis
- Hypersensitivity pneumonitis
- Ankylosing spondylitis
- Radiation
- TB
- Silicosis/sarcoidosis
122
INTERSTITIAL LUNG DISEASE
| What causes fibrosis predominately affecting the lower zones?
- Idiopathic pulmonary fibrosis
- Connective tissue disorders like SLE
- Drug-induced like amiodarone, methotrexate, nitrofurantoin
- Asbestosis
123
INTERSTITIAL LUNG DISEASE
What is the clinical presentation of interstitial lung disease?
What is a long-term complication of this?
- Progressive, exertional dyspnoea + dry cough
- Bibasal fine end-inspiratory creps, finger clubbing, cyanosis
- Cor pulmonale as fibrosis causes gradual pulmonary HTN
124
INTERSTITIAL LUNG DISEASE
What investigations would you consider in interstitial lung disease?
What is the diagnostic investigation?
- Spirometry, gas transfer test, CXR
| - High-resolution CT chest
125
INTERSTITIAL LUNG DISEASE
In ILD, what would the following show...
i) spirometry?
ii) gas transfer test?
iii) CXR?
iv) HR CT chest?
i) Restrictive = FEV1 normal/low, FVC low, FEV1/FVC increased
ii) Impaired gas exchange as reduced transfer factor (TLCO)
iii) Bilateral lower zone reticular opacities
iv) Bilateral interstitial shadowing = small, irregular, peripheral (ground glass) opacities which leads to honeycombing
126
INTERSTITIAL LUNG DISEASE
| What is the management of ILD?
- Conservative = stop smoking, pulmonary rehab
- Medical = LTOT, ?pirfenidone antifibrotic in select few
- Surgical = lung transplant curative in select few
127
ANAPHYLAXIS
What is anaphylaxis?
What are some potential causes?
- Severe, life-threatening IgE hypersensitivity reaction with sudden ABC issues
- Foods (commonest in paeds) like nuts, meds (Abx, IV contrast) + venom (stings)
128
ANAPHYLAXIS
| What is the clinical presentation of anaphylaxis?
- A = swelling of throat + tongue > hoarse voice + stridor
- B = wheeze, SOB, cyanosis
- C = hypotension + tachycardia
- D = skin/mucosal changes > widespread pruritus, urticaria, angioedema
129
ANAPHYLAXIS
| What is the acute management of anaphylaxis?
- ABCDE with 15L oxygen via NRB, IV fluid boluses required
| - IM adrenaline 1:1000 every 5 minutes to the anterolateral aspect of middle third of thigh
130
ANAPHYLAXIS
| What are the doses of adrenaline for the various age ranges?
- <6m = 100–150 micrograms
- 6m–6y = 150 micrograms
- 6–12y = 300 micrograms
- >12y = 500 micrograms
131
ANAPHYLAXIS
What is refractory anaphylaxis?
What is the management?
- ABC problems persisting despite 2 doses of IM adrenaline
| - IV fluids, expert help for ?IV adrenaline infusion
132
ANAPHYLAXIS
| What is the post-acute management of anaphylaxis once you've stabilised the patient?
- Non-sedating PO antihistamine e.g., chlorphenamine
- Serum mast cell tryptase 1–6h after event to confirm
- Specialist allergy clinic referral
- 2x adrenaline auto-injectors (300mcg) if may be exposed to trigger again
133
ANAPHYLAXIS
| What must you be cautious of after managing anaphylaxis?
- Biphasic reactions may occur
| - Risk-stratified approach to discharge crucial
134
SARCOIDOSIS
What is sarcoidosis?
Who does it normally affect?
- Multisystem disorder characterised by non-caseating granulomas
- Young, Afro-Caribbean women
135
SARCOIDOSIS
What is the acute presentation of sarcoidosis?
What systems can sarcoidosis affect?
- Erythema nodosum, swinging fever, polyarthralgia, bilateral hilar lymphadenopathy = Lofgren's syndrome
- Pulmonary, systemic, neuro, cardiac, ocular, abdo, derm
136
SARCOIDOSIS
How does sarcoidosis present in the following systems...
i) pulmonary?
ii) systemic?
iii) neuro?
iv) cardiac?
v) ocular?
vi) abdo?
vii) derm?
i) Dry cough, SOB
ii) Fatigue, weight loss, arthralgia, fever
iii) Meningitis, peripheral neuropathy, bilateral Bell's palsy
iv) Arrhythmias, restrictive cardiomyopathy
v) uveitis, conjunctivitis
vi) Hepatosplenomegaly
vii) Lupus pernio (raised, purple skin lesion on nose)
137
SARCOIDOSIS
| What investigations would you do in sarcoidosis?
- Bloods = raised ESR, ACE + calcium, reduced lymphocytes
- CXR/CT-chest
- Spirometry (restrictive)
- Tissue biopsy = diagnostic for non-caseating granulomas
138
SARCOIDOSIS
| How can sarcoidosis be staged on CXR/CT-chest?
- 1 = BHL
- 2 = BHL + interstitial infiltrates
- 3 = diffuse interstitial infiltrates only
- 4 = diffuse fibrosis
139
SARCOIDOSIS
| What is the management of sarcoidosis?
- Usually self-limiting with bed rest and NSAIDs
| - PO steroids if symptomatic stage 2/3, hypercalcaemia or eye, heart or neuro involvement
140
PULMONARY HTN
What is the normal pulmonary arterial pressure?
What is pulmonary HTN?
- 18–25mmHg
- >25mmHg which causes strain on the right heart which is pumping blood to the lungs with more resistance as well as systemic back pressure
141
PULMONARY HTN
| What is the aetiology of pulmonary HTN?
- Left heart disease = mitral stenosis/regurg, LVF
- Lung disease = COPD, interstitial lung disease, CF
- Pulmonary vasculitis = SLE, granulomatosis with polyangiitis
142
PULMONARY HTN
| What is the clinical presentation of pulmonary HTN?
- SOB #1
| - May have HF Sx (raised JVP, peripheral oedema, hepatomegaly) + can have functional TR (pansystolic murmur)
143
PULMONARY HTN
What are some investigations for pulmonary HTN?
What is gold standard?
- ECG = RVH, RAD + P pulmonale
- CXR = enlarged proximal pulmonary arteries, RVH
- ECHO = RV dilatation + hypertrophy
- Gold = right heart catheterisation showing pressure >25mmHg
144
PULMONARY HTN
| What is the management of pulmonary HTN?
- IV prostacycline analogues like epoprostenol
- Endothelin receptor antagonists like bosentan
- Phosphodiesterase-5 inhibitors like sildenafil
- CCB like nifedipine
145
OSA
What is obstructive sleep apnoea (OSA)?
What are some predisposing factors?
- Intermittent closure + collapse of upper airway > apnoeic episodes in sleep
- Obesity #1, macroglossia (acromegaly, hypothyroidism), large tonsils, Marfan's
146
OSA
| What is the clinical presentation of OSA?
- Partner often reports excessive snoring ± apnoea
- Daytime sleepiness + poor sleep quality
- HTN due to drop in blood O2 and rise in CO2 levels during apnoea
- Compensated resp acidosis
147
OSA
| What investigations would you do in OSA?
- Epworth sleepiness scale = completed by pt + partner
- Multiple sleep latency test = measures time to fall asleep in dark room
- Diagnostic = polysomnography measuring parameters such as overnight pulse ox
148
OSA
| What is the management of OSA?
- Weight loss
- CPAP first-line in mod–sev to maintain airway
- Intraoral devices like mandibular advancement if CPAP not tolerated
- DVLA informed if excessive daytime sleeping
149
MESOTHELIOMA
| What is a mesothelioma?
- Malignant tumour of mesothelial cells which line the pleura often due to asbestos
150
MESOTHELIOMA
| What is the clinical presentation of mesothelioma?
- Long latency period of 30–40y from exposure-tumour
- SOB, weight loss, chest wall pain
- Signs = finger clubbing, pleural effusion
151
MESOTHELIOMA
| What are the investigations of mesothelioma?
- Suspicion raised by CXR showing pleural effusion or pleural thickening
- Next = pleural CT + aspiration if effusion present
- Diagnostic = thoracoscopy for histology
152
MESOTHELIOMA
| What is the management of mesothelioma?
- Industrial compensation
| - Poor prognosis so symptomatic, ?chemo, ?surgery
153
GPA
| What is granulomatosis with polyangiitis (GPA)?
- Autoimmune condition associated with necrotising granulomatous small vessel vasculitis, affecting both upper/lower resp tract + kidneys
154
GPA
| What is the clinical presentation of GPA?
- URT = epistaxis, sinusitis, nasal crusting, saddle-shape nose deformity
- LRT = SOB, haemoptysis
- Renal = rapidly progressive pauci-immune glomerulonephritis (protein & haematuria on urine dipstick)
155
GPA
| What investigations might you do in GPA?
- cANCA +ve in >90%
- CXR = bilateral nodular + cavity infiltrates
- Renal biopsy may show epithelial crescents in Bowman's capsule
156
GPA
| What are the other ANCA vasculitides and how do they present?
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
- Similar = sinusitis + SOB
- Differences = asthma, pANCA + eosinophilia
Microscopic polyangiitis
- pANCA, rapid glomerulonephritis, pulmonary haemorrhage > haemoptysis
157
GPA
| What is the management of GPA?
- Steroids e.g., pred
- Cyclophosphamide
- Plasma exchange
158
ANTI-GBM DISEASE
What is anti-GBM disease/Goodpasture's syndrome?
What is the epidemiology?
- Small vessel vasculitis caused by anti-glomerular basement membrane (anti-GBM) antibodies against type IV collagen
- More common in men, bimodal age distribution + HLA-DR2 associated
159
ANTI-GBM DISEASE
| What is the clinical presentation of anti-GBM disease?
- Pulmonary haemorrhage = haemoptysis
| - Rapidly progressive glomerulonephritis = rapid onset AKI + protein/haematuria
160
ANTI-GBM DISEASE
How do you diagnose anti-GBM disease?
What is the management of anti-GBM disease?
- Renal biopsy = linear IgG deposits along the basement membrane
- Plasma exchange, steroids + cyclophosphamide
161
EAA
| What is hypersensitivity pneumonitis/extrinsic allergic alveolitis (EAA)?
- Hypersensitivity induced lung damage due to inhaled organic particles leading to a type 3 hypersensitivity reaction (immune-complex mediated tissue damage)
162
EAA
| What are some causes of EAA?
- Bird fanciers' lung = avian proteins from bird droppings
- Farmer's lung = spores from wet hay
- Malt + mushroom worker's lung
163
EAA
| What is the clinical presentation of EAA?
- Acute (4–8h post-exposure) = SOB, dry cough + fever
| - Chronic (weeks–months) = SOB, lethargy, productive cough, anorexia + weight loss
164
EAA
| What are the investigations for EAA?
- FBC = NO eosinophilia
- CXR/CT chest = upper zone fibrosis
- Bronchoalveolar lavage = lymphocytosis
- Serologic assays for specific IgG Ab
165
EAA
| What is the management of EAA?
- Avoid precipitants = #1
| - PO pred
166
ACUTE BRONCHITIS
| What is acute bronchitis?
- Inflammation of the trachea + major bronchi + so is associated with oedematous large airways + sputum production
167
ACUTE BRONCHITIS
| What is the clinical presentation of acute bronchitis?
- Cough ± productive
- Sore throat, rhinorrhoea but not really SOB
- Normal chest exam but may have low-grade fever + wheeze, no focal creps
168
ACUTE BRONCHITIS
| What is the management of acute bronchitis?
- First line Abx = PO doxy, if not PO amox
- CRP 20–100mg/L = delayed Abx, >100 = Abx
- Systemically very unwell or pre-existing comorbidities = Abx
169
INFLUENZA
| What is the pathophysiology of influenza?
- RNA virus which exists in three serotypes: A, B (most common) and C which is determined by surface antigens haemagglutinin + neuraminidase which are rearranged in host organisms such as animals to produce different strains
170
INFLUENZA
| What is the clinical presentation of influenza?
- Fever ≥37.8
- Coryzal Sx
- Fatigue
- Myalgia
- Headache
- Dry cough
- Sore throat
171
INFLUENZA
| How do you investigate influenza?
- Viral nasal/throat swabs for PCR
| - COVID-19 PCR
172
INFLUENZA
| What are some complications of influenza?
- Pulmonary = viral or secondary bacterial pneumonia, worsening of chronic disease
- Neuro = encephalitis
- Cardio = myocarditis
173
INFLUENZA
| What influenza prophylaxis is available and who is able to receive it?
- Free influenza vaccination
| - ≥65, young children, pregnant women, those with chronic health conditions (COPD, asthma, DM) + healthcare workers
174
INFLUENZA
| What is the management of influenza?
- Mostly supportive with analgesia, antipyretics, fluids + oxygen
- Infection control/isolation measures
- If risk of complications = PO oseltamivir (Tamiflu)
175
ATELECTASIS
| What is the pathophysiology of atelectasis?
- Collapse of either basal alveolar or even most/entire lobes caused by resorptive atelectasis as residual air in affected lung resorbed by circulating blood at greater rate than it's replaced by ventilated air causing volume loss + opacification on CXR
176
ATELECTASIS
| What are the causes of atelectasis?
Bronchial obstruction
- Luminal = foreign object, mucus plugging, misplaced endotracheal tube
- Mural = lung cancer
177
ATELECTASIS
| What is the clinical presentation of atelectasis and how would you investigate it?
- SOB + hypoxia, especially 72h post-op
| - CXR = air space opacification, tracheal deviation towards atelectasis
178
ATELECTASIS
| What is the management of atelectasis?
- Position pt upright, treat cause
| - Chest physiotherapy with deep breathing exercises
179
ABPA
| What is allergic bronchopulmonary aspergillosis (ABPA)?
- Allergy to Aspergillus spores often with background of bronchiectasis + eosinophilia
180
ABPA
| What is the clinical presentation of ABPA?
- Bronchoconstriction = wheeze, cough, dyspnoea
| - Proximal bronchiectasis
181
ABPA
| What investigations and management would you do in ABPA?
- FBC = eosinophilia
- Immediate positive radioallergosorbent (RAST) test to Aspergillus
- Positive IgG precipitins + raised IgE
- PO pred 1st line, ?itraconazole 2nd line
182
OCCUPATIONAL LUNG DISEASES
| What is the pathophysiology of coal worker's pneumoconiosis?
- Inhaled coal dust is engulfed by macrophages which becomes overwhelmed + accumulate in alveoli triggering an immune response damaging lung tissue
183
OCCUPATIONAL LUNG DISEASES
| What are the two types of coal workers' pneumoconiosis?
- Simple pneumoconiosis = commonest, no Sx, increased risk of lung diseases (COPD)
- Progressive massive fibrosis = upper zone fibrosis, SOBOE + cough
184
OCCUPATIONAL LUNG DISEASES
| What various pathologies can result due to asbestos exposure?
- Pleural plaques
- Pleural thickening
- Asbestosis
- Mesothelioma + lung cancer
185
OCCUPATIONAL LUNG DISEASES
What are pleural plaques?
What is the management?
- Benign and do not undergo malignant change
| - No follow up
186
OCCUPATIONAL LUNG DISEASES
| How does asbestosis present?
- Lower lobe fibrosis presenting with SOB + reduced exercise tolerance
- Severity related to length of exposure (unlike mesothelioma)
187
OCCUPATIONAL LUNG DISEASES
| What are the investigations and management for occupational lung diseases?
- CXR = fibrosis (zone depends on condition)
- Spirometry = restrictive pattern
- Avoid exposure if possible + industrial compensation via Industrial Injuries Act
188
ARDS
| What is acute respiratory distress syndrome (ARDS)?
- Increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli (non-cardiogenic pulmonary oedema)
189
ARDS
| What are the causes of ARDS?
- Pulmonary = chest sepsis, inhalation injury, transfusion-related lung injury, aspiration
- Non-pulmonary = other sepsis, DIC, acute pancreatitis
190
ARDS
What is the clinical presentation of ARDS?
How is ARDS diagnosed?
- Acute onset + severe SOB, tachypnoea, bilateral lung crackles + hypoxia
- American-European Consensus Conference
191
ARDS
| What are the aspects of the American-European Consensus Conference for ARDS diagnosis?
- Acute onset (<1w of known risk factor)
- Pulmonary oedema = bilateral infiltrates on CXR
- Non-cardiogenic (pulmonary artery wedge pressure if doubt)
- PF ratio (pO2/FiO2) <40kPa implies acute lung injury, <28kPa severe on ABG
192
ARDS
| What is the management of ARDS?
- ITU setting as high mortality, prone positioning
- Oxygenation/ventilation for hypoxaemia with low tidal volume
- General organ support e.g., vasopressors to maintain MAP >60mmHg
