1
Q
What is spirometry?
A
assesses lung function by measuring expiration volume after max inhale
differentiates between obstructive and restrictive lung disease
Includes FEV1, FVC, and % (normal 0.7)
2
Q
What is FEV1? Normal values?
A
Forced expiratory volume in 1’s
Volume exhaled in 1st second after deep inspiration and forced expiration
80% or greater than predicted is normal
3
Q
What is FVC? Normal values?
A
Forced Vital Capacity
Total volume of air that patient can forcibly exhale in one breath
- *80% or greater** than predicted is normal
- *Low = airway restriction**
4
Q
How are the results of spirometry expressed?
A
FEV1 / FVC
in %, best of three readings
Normal is >0.7
5
Q
What does it mean to have an obstructive spirometry pattern?
A
FEV1/FVC below 0.7 = obstruction
6
Q
What does it mean to have a restrictive spirometry pattern?
A
Normal FEV1/FVC > 0.7
but FVC is low = restriction
7
Q
Name a few obstructive diseases?
A
COPD, asthma, emphysema, bronchiectasis, bronchiolitis,
cystic fibrosis
8
Q
Name a few restrictive diseases?
A
Pulmonary
Pulm fibrosis, Pulm oedema, TB !
Non pulm
kyphoscoliosis, neuromuscular disease, connective tissue disease, obesity, pregnancy
9
Q
What is reversibility?
A
Bronchodilator responsiveness - see if lung function gets better with meds
If
reversible - + asthma likely diagnosis
not reversible - fixed obstructive patho
partially reversible - coexist
10
Q
How might you assess reversibility?
A
Spirometry → Administer bronchodilator → repeat
Test with 400 microgram salbutamol
11
Q
Compare and contrast asthma & COPD?
A
Asthma
variable airflow obstruction
reversible
COPD
fixed airflow obstruction
may be mixture
12
Q
What is COPD?
A
Chronic Obstructive Pulmonary disease
persistent airflow limitation, not fully reversible
progressive, assoc chronic bronchitis & empysema
13
Q
What is chronic bronchitis?
A
Cough with sputum for 3 months
2 or more years
- *Hypertrophy & hyperplasia of bronchi** = bronchoconstriction, - airflow,
- *narrowing of airways**
14
Q
What is emphysema?
A
Histological!
Enlarged airspaces distal to terminal bronchioles, with destruction of alveolar walls
loss of elastic recoil = - expiratory airflow
loss of alveoli = loss of SA for exchange
= airway collapse during expiration
15
Q
Risk factors for COPD?
A
Cigarette smoke
Occupational exposure to pollutants, dust, chemicals, smoke
alpha-1 antitrypsin deficiency
recurrent lung infections
16
Q
How might cigarette smoke cause COPD?
A
Mucus gland hypertrophy in large airways
= increase in WBC (N, M & L) & release of inflam mediators →
structural changes in lung = emphysema
17
Q
Presentation of COPD (4)?
A
Productive cough
with white or clear sputum
Breathlessness - even at rest
prolonged expiration, poor chest expansion
lungs hyperinflated = barrel chest
Pursed lips on expire = prevent alveolar & airway collapse
18
Q
Extra-pulmonary manifestations of COPD?
A
Pulmonary hypertension
= fluid retention, peripheral oedema
= (severe) RV hypertrophy, cyanosed
Weight loss, reduced muscle mass, general weakness, osteoporosis, depression
19
Q
Function of alpha-1 antitrypsin in normal person?
A
secreted by liver, acts in parenchyma
Inhibits elastase
= protease that breaks down elastin
Elastin = important for
structural integrity of alveoli
20
Q
How might alpha-1 antitrypsin deficiency caused COPD present?
A
Early onset, family history!
auto recess
smoking still +++ risk tho
a-1 a = hepatic secreted elastase inhibitor, deficiency = breakdown of alveoli = emphysema
21
Q
Investigations for COPD (4)?
A
Lung function test
FEV < 80
FEV1/FVC < 0.7 = obstruct
CXR / CT
normal / hyper inflated lungs = low flattened diaphragm, long narrow heart shadow
reduced peripheral lung markings
bullae = airspace >1cm, complete destruct of lungs
FBC = chronic hypoxia
alpha-1 antitrypsin levels / genotypes
esp in premature disease & lifelong non smokers
22
Q
What is peak flow?
A
= test of peak flow rate during forced expiration following max inspiration
Varies with:
diurnal (high afternoon low early)
age, gender, height
23
Q
How might you differentiate between asthma & COPD (in investigations)?
A
Repeat peak flow to exclude asthma
24
Q
Classification of stages of COPD?
A
Stage 1 - FEV1 <80%
Stage 2 - FEV1 50-79
Stage 3 - FEV1 30-49
Stage 4 - FEV1 <30%
25
Lifestyle tx before pharm tx (5)?
**stop smoking!!!** duh
pneumococcal and influenza vaccinations
pulmonary rehab if indicated
make a self management plan with patient
treat comorbidities
26
Pharma tx principles for COPD?
1st line = **SABA / SAMA**
2nd- Steroid responsive / asthma features?
yes - **LABA + ICS**
no - **LABA + LAMA**
3rd
**(LABA + LAMA) + ICS 3 months**
= if 2nd & still affect QoL
**(LABA + LAMA) + ICS**
= if 1 severe or 2 modern exa / year
**(LABA + ICS) + LAMA**
QoL or 1s2m/y
27
What are SAMA / LAMAs? Examples?
**Antimuscarinics** = competitive inhibitor of Acetylcholine → reduce smooth muscle tone
= **bronchodilation**
-ium ending!
Short = **ipratropium**
Long = **titropium**, **glycopyroonium**, **aclidinium**
28
What are SABA/LABAs? Examples?
**Beta 2 agonists** = smooth muscle relaxation, (K+ to cells)
Short = **salbutamol. terbutaline**
Long = **salmeterol, formoterol**
29
What are ICS? Examples?
**Inhaled corticosteroids** = alternates transcription so reduces IL & chemokines, increases antiinflam proteins → **reduce mucosal inflammation, widen airways & reduce mucus secretion**
Examples **= beclometasone, budesonide, fluticasone**
30
Pathophysio of asthma!
**Airflow limitation**
**Airway hyper responsiveness**
**Bronchial inflammation** → plasma exudate oedema, smooth muscle hypertrophy, mucus plugging and epithelial damage
31
Cells involved in airway inflammation in asthma?
Main mediator = **IgE**
**Mast cells** → histamine = bronchoconstrict, prostaglandin, cytokine, IL345
**Eosinophils** → by IL3 & 5
**Dendritic cells & lymphocytes:** present allergens to lymphocytes & release cytokine
32
Two main types of asthma?
**Allergic / eosinophilic asthma** (70%)
allergens & atopy
**Non-allergic / non eosinophilic** (30%)
Exercise, cold air & stress
smoking, obesity
33
Non-acute attack symptoms of asthma?
**Nocturnal worse**: cough / dyspnoea
frequent in children
intermittent **dyspnoea, wheeze, sputum**
May be linked to ‘**provoking** †’ = allergens, infections, men-cycle, exercise, cold air
34
Features of an asthma attack?
reduced chest expansion / prolonged expiratory time / bilateral expiratory polyphonic wheezes / tachypnoea
severe = silent chest / cyanosis (PaO2 \< 8kPa) / bradycardia / PEFR \< 33%
35
Immediate management if life threatening attack?
**Oxygen** to maintain O2
Nebulised 5mg **salbutamol** + **ipratropium** - repeat / IV
**Prednisolone** ( ± hydrocortisone IV)
**ABG**, repeat in 2hrs
**PEFR** regularly
**Oximetry** → SaO2 \> 92%
CXR if no response
36
How might you diagnose asthma?
**RCP3 questions** - nocturnal / usual in a day? / interfere with daily living?
1- **Lung function test**
2. **Nitric oxide FeNO test**
3. **Peak flow readings**
blood & **sputum test** → **_eosinophilia in sputum = specific!_**
**Skin prick allergen** test
**Asthma control test**
25 good, 20-24 on target, 20 = off
37
What will an asthmatic lung function test look like?
**Peak expiratory flow rate PEFR** - measure on waking, prior to b.d. & before bed, after bronchodilator
→ diagnostic if **\> 15% improvement on FEV1 or PEFR follow b.d.**
**Spirometry** = assess reversibility
**Exhaled nitric oxide** = assess efficacy of corticosteroids
Carbon monoxide test = normal
38
How might you distinguish asthma from COPD?
COPD = **later** disease, **smokers**
**Progressive** short of breath with _wheeze_ as a part of symptom complex
= less day to day variation
winter symptoms and sputum production in COPD
\* but can overlap!
39
Treatment algorithm for asthma in \>17? (NICE)
Short term, 1st: SABA
Maintenance 1st: ICS + SABA
+ LTRA
then onwards, LTRA optional
+ LABA
+ LABA in MART
Sebastian's steroids went ultra fast in a lazy supermarket
MART = maintenance and reliever therapy
40
Treatment algorithm for asthma in 5-16?
Short = SABA
Maintenance
ICS + SABA
ICS + LTRA
ICS + LABA
Then
Maint: ICS + LABA in MART
Short: ICS + LABA in MART
Then
Main: up ICS + LABA in MART or fixed
Short: ICS + LABA in MART
or change to SABA
41
**Beta agonists** for **asthma**
Effective time, examples and type of agonist?
**Short acting BA - 4 hours**
Salbutamol = partial agonist
Terbutaline
**Long acting BA - 12 hours**
Salmeterol
Formoterol = full agonist
42
How does LABA last longer and what should you be careful of with badly controlled asthmatics?
LABA = longer since more lipophilic = remain in tissue longer
In badly controlled asthmatics - high concentration may lead to **tolerance** due to B2-receptor desensitisation
43
Types of ICS for asthma?
= semi-synthetic glucocorticoids
Budesonide, beclomatasone, prednisolone
| (mineralo involves aldosterone so Na+)
44
What is an LTRA?
Leukotriene receptor antagonist
e.g. montelukast
45
What is bronchiectasis?
Chronic infection of the bronchi & bronchioles → **airway distortion & dilatation with inflam process in wall of the airway**
Results from pulmonary inflammation & scarring due to _infection_, bronchial obstruction or fibrosis
46
Risk factors for bronchiectasis?
women \> men, increase w/age
pathological endpoint for many diseases
HIV, UC, RA!
* *post INFECTIONS**
e. g. pneumonia, TB, measles, pertussis
47
Causes of bronchiectasis?
**Infections**!!
again, pneumonia, TB, measles, pertussis, whooping cough
**Congenital**
CF, Kartagener's
**Mechanical obstruction**
foreign body, lymph node, tumour
48
Briefly describe pathophysiology of bronchiectasis (again)?
Failure of mucociliary clearance + impaired immune = insult to bronchial wall → uncontrolled **inflammation** → **bronchitis → bronchiectasis → fibrosis**
49
Present - bronchiectasis?
**Productive** cough with large amounts of foul smelling, discoloured (khaki / green) **sputum**
occasional haemoptysis
Infection = + sputum volume, + purulence
* *Finger clubbing**! esp CF
* *Chest pain**!
Dilated, thick bronchi on CT
50
Investigations for bronchiectasis?
Usually lower lobes affected!
**CXR**
cystic shadows: cysts w/ fluid
dilated bronchi & thickened walls = **tramlines & ring shadows**
**High Res CT**
Thickened, dilated bronchpi + cysts
always \> assoc. blood vessels
Spirometry = obstructive
**Bronchoscopy to sputum culture!**
51
Common causal organisms for bronchiectasis?
H. influenza
S. pneumoniae
S. aureus
P. aeruginosa
52
Treatment for bronchiectasis?
**Improve mucus clearance**
chest physio, mucolytics, postural drain
* *Antibiotics**
* *H. influenza** = amoxi / co-amoxiclav / doxycyline but if resistant = IV cephalosporin
* *S. aureus** = flucloxacillin
* *P. aeroginosa** = high dose oral ciprofloxacin
Anti-inflammatory agents = long term azithromycin can reduce exacerb freq
53
What is cystic fibrosis?
Disease of exocrine gland function affecting mainly caucasians
**auto recess!**
multi system usually w/ pancreatic insuff
54
Pathophysio of cystic fibrosis?
Mutation on chromosome 7
= **defective** CF transmembrane regulator **(CFTR) protein**
defective Cl- secretion & increased Na+ absorption in airways = increased H2o absorp → **thickened secretion in number of organs**
55
How might CF manifest in the lungs?
= **dehydrated airway surface liquid**,
= mucus stasis, airway inflam & recurrent infection
predisposed to chronic pulmonary infections + progressive obstruct
**final = bronchiectasis**
56
How might CF present extra-pulmonarily?
**_Salty sweat!!_**
Reduced pancreatic enzymes → **_pancreatic insufficiency_** (DM & steatorrhoea)
Distal intestinal obstruction syndrome
= **_reduced GI motility_**, maldigest & malabsorp
Male urogenital abormality, female amenorrhea
57
How might you test for cystic fibrosis?
fam hist + clinical hist
**_Sweat test_**
= high [Na+] & [Cl-], \>60mmol/L
**_Genetic screening_** for CF mutations
**_Faecal elastase test_**
tests for protease - produced by pancreas
in CF - low to none
**_cough swab, sputum culture_**
58
Treatment for cystic fibrosis?
Stop smoking
FEV1 & BMI every appt
**Prophylactic**
antibiotics
pseudomonal & flu vaccine
**Pharm**
BA & ICS = symptomatic relief
Mucolytics = clear airway mucus
Replace pancreatic enzyme
Bilateral lung transplant
59
Antibiotics for -
s. aureus
h. influenza
MRSA
p. aeruginosa
* *s. aureus** = flucloxacillin
* *h. influenza** = amoxicillin
* *MRSA** = rifampicin & fucidin
* *p. aeruginosa** = ciprofloxacillin & nebulised colomycin
60
Complications for cystic fibrosis?
gallstones, liver cirrhosis
end stage = bronchiectasis
61
What is sarcoidosis?
Multisystem inflammatory disease affecting the lungs & intrathoracic lymph nodes
= interstitial lung disease
62
Pathophysio of sarcoidosis?
T cell mediated granulomatous disease
non-caseating sarcoid granulomas consisting mainly of T cells
mainly mediastinal **lymph nodes & lung**
63
risk factors for sarcoidosis?
20-40 years, women
afro-caribbeans more frequent
& severe - particularly extra-thoracic disease
fam hx (first degree)
64
Presentation - sarcoidosis
Incidental find on CXR common
= **infiltrate & extracellular matrix deposition in lung distal to terminal tubule**
**lymphadenopathy** = swole lymph nodes in neck!
painless, no swallow difficulty
can affect any organ but predilection to **lung & lymph node**
cancer symptoms / systematic
65
Acute sarcoidosis - symptoms?
**Erythema nodusum** - on shins, thigh & forearm ± polyarthralgia
both may spontaneous resolve / come and go
66
Investigations for sarcoidosis?
**DIAG = tissue biopsy**
→ non-caseating granuloma
```
**CXR for staging**
Bronchoalveolar lavage (BAL) - increased lymphocytes in active disease
```
Lung function test
Blood = raised ESR, **ACE!!!**
LFT, Ca2+, lymphopenia
67
Staging for sarcoidosis?
* *0** - normal
* *1** - bilateral hila lymphadenopathy (BHL)
* *2** - pulm infiltrate with BHL
* *3** - pulm infiltrate without BHL
* *4** - prog pulm fibrosis, bulla formation = honeycombing & bronchiectasis
68
Treatment for sarcoidosis?
_No treatment for_
those with **bilateral hilar lymphadenopathy** = no tx = spont resolve
symptomatic at stage 1, asymptomatic at stage 2
treat acute, transplant for severe
69
How might you treat acute sarcoidosis?
**Bed** **rest**
**NSAIDs**
**Corticosteroids**
= prednisolone oral then wean
severe = IV methylpred
steroid resistant = methotrexate but needs close monitoring
70
What is idiopathic pulmonary fibrosis?
Chronic condition characterised by progressive fibrosis of unknown aetiology
= interstitial lung disease
71
Risk for IPF?
commonly related to other interstitial diseases - sarcoidosis, chronic hypersensitivity pneumonitis, autoimmune stuff
50+ age!
fam hx - familial PF
72
What is interstitial lung disease?
group of diseases affecting the lung **insterstitium** (**tissue & space around air sacs of lungs**)
73
Features of IPF?
* *Chronic exertional dyspnoea**
* *bilateral inspiratory crackles**
* *clubbing**
* *acrocyanosis** (peripheral discoloration indicative of cyanosis)
74
Investigations for IPF?
**High Res CT = key**
in basal lung / periphery
subpleural reticulation / reticular opacity
traction bronchiectasis
emphysema / loss of lung volume
honeycombing
_Lung function tests_
_Bloods_
**Biopsies** - bronchoalveolar lavage / transbronchial biopsy etc
75
Management in IPF?
**Supportive**
O2, exercise, opiates
**Treat cough**
**Pharma w/ specific criteria**
Pirfenidone (anti-inflam), nintedanib (slow fibrosis)
**Lung transplant where appropriate**
76
Pulmonary hypertension - criteria?
using
mean pulmonary artery pressure (mPAP)
77
Conditions associated with pulmonary hypertension?
1e = Connective tissue disease - SLE
Left heart failure - MI / systemic
(test using brain natriuretic peptide, ECG etc)
COPD, pulmonary embolism
Sarcoidosis, glycogen storage disease & haem disorders
78
How might you treat pulmonary hypertension?
Warfarin - intrapulmonary thrombosis
Diuretics for oedema
Prostanoids = IV epoprostenol
Oral endothelin receptor antagonist = bosenten
Phosphodiesterase-5 inhibitors = sildenafil
79
What is hypersensitivity pneumonitis?
ILD
Inhalation of allergens provoking a hypersensitiivity (type 3 / 4 reaction)
80
Nature of hypersensitivity pneumonitis?
adult onset, occupation related!
81
Compare and contrast asthma x hypersensitivity pneumonitis?
* *_Asthma_**
- type I IgE
- inflam around airway (bronchial)
- **eosinophilic inflam**
- eventual - irreversible airway changes
* *_Hypersensitivity pneumonitis_**
- type III or type IV IgG
- inflam around alveoli and lung interstitium
- **neutrophilic inflam**
- eventual = fibrosis
82
Pathophysio of hypersensitivity pneumonitis?
allergic reaction to inhaled antigen → **granulomatous inflammation of lung parenchyma**
= sensitised by repeat inhalation of the antigen
* *acute / subacute** = recurrent
* *chronic** = fibrosis, emphysema & perm lung damage
83
Occupations at risk and subtypes of hypersensitivity pneumonitis?
_Farmer's lung_ = most common
exp to _fungus_ in mouldy hay
_Bird/pigeon fanciers lung_ = also common
exp to avian proteins & droppings
_Cheese-workers lung_ = exp to mouldy cheese
_Malt-workers lung_ = exp to mould malt
_Humidifier fever!_ = contaminated humidifying systems in AC / humid in factories, esp printing works
84
Present - farmer's lung?
**acute dyspnoea & cough**
hours after inhalation
may resolve upon withdrawal of antigen
```
earliest = bronchiolitis
then = non-caveating granulomas
comp = pulmonary fibrosis
```
85
Acute & chronic presentation for hypersensitivity pneumonitis?
fever, rigors, myalgia
dry cough, dyspnoea, crackles no wheeze, tight chest
→ related to lvl of exposure
_chronic_
- usually no hist of preceding acute symptoms
- partial improvement when remove trigger
- cyanosis / clubbing / weight loss
- T1 resp failure
86
How might you diagnose hypersensitivity pneumonitis?
* *CXR**
- fibrotic shadow in **upperzone of lung** (mottling / consol)
- diffuse small nodules / + reticular shadowing
* *Lung function test**
- reversible restrictive defect
- reduced gas transfer during acute attacks
**Bronchoalveolar lavage**
→ analyse lymphocyte count & CD4/8 ratio
87
How might you treat hypersensitivity pneumonitis?
_acute_
remove allergen, O2
oral prednisolone followed by reducing dose
_chronic_
avoid exposure
long term steroids
88
Name some defensive mechanisms that protects the respiratory tract from infections?
**Skin**!
* *Intestines**
- acidic stomach, enzymes, commensal bacteria, thick mucosa barrier
**Urinary system**
sterile & flows outwards
**Vagina**
acidic pH / mucus barrier / commensal bacteria
89
Defensive mechanism of the lungs to protect against pathogens in respi tract?
**Mucus barrier & cough**
**Humoral & cellular immunity**
WBC & soluble factors
**Commensal flora**
**Swallowing**
push into intestines = strong acid
90
Upper respiratory tract infections?
91
What is pharyngitis / tonsilitis?
**Infections in throat that causes inflammation**
```
tonsils = primarily affected = tonsilitis
throat = pharyngitis
```
92
Causes of pharyngitis?
**Viral = 80%**
rhinovirus / adnovirus
Epstein Barr virus, acute HIV
**Bacterial**
Group A beta haemolytic strep pyogenes (GABHS)
93
Presentation for pharyngitis?
sore throat / fever
* *oropharynx & soft palate = red**
* *tonsils inflamed and swollen**
1-2 days → tonsil lymph nodes enlarge
94
Treatment for GABHS caused pharyngitis?
Amoxicillin
95
How might you decide if a sore throat is caused by a bacterial infection or not?
→ **Centor criteria**
3-4 positive = 40-60% likely bac
tonsillar exudate
tender anterior cervical adenopathy
fever over 38 degrees by hx
absence of cough
96
What is sinusitis?
Infection of paranasal sinuses
mostly bacterial sometimes fungal
97
Causes for sinusitis?
Strep pnuemoniae (40%)
Haemophilus influenza (30-35%)
assoc. Upper RI infect / asthma
98
Present / diagnosis of sinusitis (2 key)?
Frontal headache ± fever
**Purulent rhinorhea** = nasal cavity filled with mucus fluid
= **purulent nasal discharge**
**Unilateral facial pain**, potentially with **tenderness**
99
Treatment for sinusitis?
**Nasal decongestant** e.g. xylometazoline
* *Broad spectrum antibiotics**
e. g. co-amoxiclav (h.i. can be resistant to amoxicillin)
**complications**
brain abscess, sinus vein thrombosis, orbital cellulitis
100
Acute epiglottitis - what is it?
**Inflammation of epiglottis**
= flap of cartilage behind roof of tongue → depressed during swallow to cover windpipe
101
Risk / epidemiology of acute epiglottitis?
**Formerly in children \< 5y/o**
severely ill, life threat
now = rare → **_HiB vaccine_**
**adults**
severe = **h. influenza**
can be from pharyngitis / other bac infect of airway
immunocompromised - AIDS
102
Clinical presentation for acute epiglottitis?
Sore throat
**pain on swallowing = odynophagia**
**Inspiratory stridor** = high pitched wheeze when breathing in
if long hx, fatigue, weight loss, diarrhoea
103
Investigate / results for acute epiglottitis?
Sagittal view
upper respiratory tract XR
= thumb sign
104
Treatment for HiB caused acute epiglottitis?
**_Doxycycline or co-amoxiclav_**
20% amoxicillin resistant
not susceptible to macrolides (erythromycin / clarithromycin)
105
What is whooping cough? What causes it?
disease of childhood, 90% \<5 yo
caused by **Bordatella pertussis** = gram neg coccobacillus (rod)
106
Clinical presentation for whooping cough?
**Chronic cough** in spasms (\<14d)
inspiratory whoop = in younger
usually **end in diarrhoea**
**rhinorhoea, conjunctivitis**
may px as subconjunc haemorrhage
107
Investigations & results for whooping cough?
Lungs clear to auscultation
**Respiratory culture** - 90% positive for B. pertussis [gram neg]
**PCR/ ELISA** for IgG against pertussis toxin
108
Treatment for whooping cough?
**Antimicrobials = clarithromycin**
reduce symptoms earlier (1-6 weeks), less effective later
Should eliminate carriage in household = chemoprophylaxis
**Vaccination**
acellular pertussis as a part of dTaP
109
Diagnose:
3y, M
prominent barking cough, febrile, has inspiratory stridor
febrile, cyanosed with intercoastal recessions
Croup / acute laryngotracheobronchitis
110
Cause & pathophysio for Croup / acute laryngotracheobronchitis?
**Parainfluenza viruses**
inflammatory oedema extend to vocal cords & epiglottis = **narrow of airway**
progressive airway obstruction = **cyanosis**
111
Treatment for croup?
**Nebulised adrenaline** for short term relief
Oral / intramuscular **corticosteroids** (dexamethasone) w/ **oxygen** & **fluids**
112
Pneumonia - what is it?
Acute lower respiratory tract infection
= inflammation of the lung parenchyma
113
People at risk of pneumoniae?
**Immunocompromised**
infants & the elderly
nursing home residents
**Comorbidities**
COPD, chronic lung diseases
people w/ impaired swallow conditions \*neuro etc)
Diabetes, congestive heart
114
Pathology of pneumonia?
Bacteria **translocate** to normally sterile distal airway → **overwhelm resident host defence** → **inflammatory** **response** → bac cleared
115
Pneumonia symptoms?
| (think of big 3 areas - not signs!)
**Infection**
fever, sweats, sputum
no sputum in atypical org
**Chest**
short of breath, pleuritic chest pain (worse on deep breath)
**Illness**
weakness, malaise
sometimes extra pulm features
116
rusty sputum & pleuritic chest pain, raised WBC, multi-lobar consolidation
- causing organism?
S pneumoniae
117
Differentiate S pneumonia from S aureus?
S pneumonia = multi lobar
S aureus = multi lobar + multiple abscess
118
flu like symptoms, ± sputum, neuro / GI features
_upper_ lobe cavity
- causing organism?
Legionella spp.
| (but exclude TB first as TB also upper lobe)
119
± sputum, pneumonia features with a rash - causing organism?
rash = mycoplasma spp. !
120
Signs of pneumonia?
**Infection**
+ HR, RR, low BP
fever, dehydration
**Chest**
= signs of **lung consolidation** on percussion & auscultation
**_dull to percussion_**
decreased air entry
crackles ± wheeze
increased vocal resonance
121
Investigations for pneumonia?
**CXR**
**FBC + Biochemistry**
WBC (= marker of sev)
C-reactive protein = inflammation marker, diag + assess
**Pulse oximetry**
**Microbiological tests**
122
CXR signs for pneumonia?
**airspace opacification**
filling of the alveoli with infectious material and pus
patchy → confluent as infection develops
**air bronchograms**
air-filled bronchi running through pus-filled alveoli
(black branches in white)
123
Microbiological tests for pneumonia?
**Sputum culture & sensitivities**
**Urinary antigen**
Legionella & S pneumonia
**PCR**
viruses & mycoplasma
Consider **acid fast bacilli stain & culture (TB)** if features suggestive
124
Community acquired pneumonia - causative organisms (6)?
Strep pneumoniae = most common
H influenza
Klebsiella pneumoniae
**Atypical**
Mycoplasma pneumoniae
Chlamydophila pneunominae
Legionella sp.
125
How might you assess severity of CAP?
using the CURB-65 score
126
CURB 65 criteria?
| (pls know)
Confusion
Urea (\> 7mmol/L)
might not be present in community so ignore
Respiratory rate (\> 30 / min)
BP \< 90/60
Age \> 65
127
Response according to CURB 65?
0-1 mild, admit if special circ
2 - moderate - admit!
3-5 - admit & monitor closely
4-5 admit to critical care
(no urea in comm so 0, 1-2 mod, 3-4 severe)
128
CAP treatment based on CURB score? Tx duration?
**mild 0-1**
amoxicillin
alt: clarithromycin or doxycycline
**moderate 2**
amoxicillin plus clarithromycin
**severe 3-5**
IV co-amoxiclav + clarithromycin
alt: cefuroxime & clarithromycin
* *5 days** mild to mod, + if severe
* *14-21 days** S aureus, gram neg & legionella
129
Other indicators of severity for pneumonia?
* *Delerium** = confusion
* *Renal impairment** = + urea
**Increased oxygen demand, hypoxaemia**
+ RR, lactic acid production
**BP drop**
**→ signs of _sepsis_!**
130
Treatment for pneumonia
**S. pneumonia**
nature of bac
tx?
gram positive
alpha haemolytic optochin sensitive
**beta lactam** = amoxicillin, cefuroxime, cefotaxime
* *alt**
* *macrolides** = clarithromycin, fluoroquinolones, ciprofloxacin
131
Treatment for pneumonia
**H. influenza**
nature of bac
tx?
gram neg cocobacilli
* *beta lactam** = amoxicillin, co-amoxiclav
* *tetracyclines** = doxycycline
NOT macrolides!!
132
Treatment for pneumonia
**S. aureus**
nature of bac
tx?
gram pos
beta lactams = flucloxacillin, cefuroxime
if MRSA = vancomycin, linezolid
133
Treatment for pneumonia
**Klebsiella pneumonia**
nature of bac
tx?
gram neg, entero
beta lactam = co-amoxiclav, cephalosporins
134
General ‘atypical’ pathogen tx principle?
special antibiotics
=
macrolides
Erythro / claritho
fluoroquinolones
ciprofloxacin
tetracyclines
doxycycline
135
Legionella features?
warm water
tanks, AC, travel
severe illness, resp failure
**extra pulmonary** = diarrhoea, GI & consudion
136
Mycoplasma features?
younger adult, milder illness
extrapulm features = **rash (erythema multiforme),** haemolytic anaemia, Raynauds, bullous myringitis, enceph
137
Prevention of pneumonia?
Vaccine!
Polysaccharide pneumococcal vaccine for \> 65
Pneumococcal conjugate for children
138
Complications of pneumonia?
**Respiratory failure**
**Hypotension**
due to comb of dehydration + vasodilation from sepsis
**Parapneumonic effusion**
**Empyema**
139
What is parapneumonic effusion? Investigate?
any pleural effusion secondary to pneumonia (bacterial or viral) or lung abscess
→ **thoracocentesis** to remove fluid from pleural space, aka pleural tap
**→ CXR** = signs of pleuritic effusion
140
What is of empyema?
pleural effusion, but fluid is infected by bacteria!
= **pus / purulent fluid in pleural space**
fluid = yellow / turbid, pH \< 7.2, low glucose
141
Signs of empyema?
* *ongoing fever**
* *failure of WBC / CRP to settle on antibiotics**
**Pleuritic pain** (on deep insp)
**Signs of pleural collection**
= stormy dull percussion, reduced air entry
142
Treatment for empyema / complicated parapneumonic effusions?
**Drainage** - chest tube / cardiothoracici surgery
**Antimicrobials**
co-amoxiclav
meropenam for anaerobic coverage
143
Lung abscess - people at risk?
in **aspiration pneumonia, inapp tx CAP**
* *alcoholics, those with poor dentition**
* *metastatic infection** from right heart & venous system - IVDU, Lemierre's
**TB, septic emboli**
144
Causative organisms & nature - lung abscess?
**Strep milleri**
= alpha haemolytic optochin resistant
**Klebsiella pneumonia**
& other gram neg bac
**Anaerobes!!!**
ensure microbio coverage
145
Treatment for lung abscess?
= prolonged antibiotics for 6 weeks +, surgical drainage if required
146
Hospital acquired pneumonia - criteria? signs?
Acquired at least 48 hours after hospital admission
new fever, purulent secretions,
new radiological infiltrates / CRP increase, + O2 requirements
147
Hospital acquired pneumonia - causative organisms?
**S. aureus** (& MRSA)
strongly ventilator associated
**Pseudomonas aeruginosa**
* *Acinetobacter baumanii**
* *Klebsiella pneumoniae**
* *E. coli**
148
Treatment for early onset hospital acquired pneumonia (CAP organisms)
Metronidazole
Beta lactams with inhibitor of beta lactamase = co-amoxiclav, piperacillin-tazobactam
149
General, go to antibiotic if hospital acquired?
Start broad then focus
* *→ doxycycline**
* *→ piperacillin-tazobactam or cefurioxime**
150
Treatment for s. aureus HAP?
beta-lactam = flucloxacillin, cefuroxime
if MRSA - vancomycin
151
Treatment - pseudomonas aeruginosa?
Anti-pseudomonal penicillin
= piperacillin-tazobactam
152
What is bronchitis - acute vs chornic?
acute = self limited **inflammation of the epithelia of the bronchi** due to _upper airway infection_
chronic = condition in COPD, cough \> 3m in 2 conseq years
153
Signs & causes of bronchitis?
cough, often wheeze \> 5 days
± phlegm
no fever / signs of infection!
majority viral, rarely bacterial in healthy adults
154
Investigate & treatment, bronchitis?
* *CXR** - normal
* *Viral & bacterial throat swabs** = PCR for resp viruses & mycoplasma, culture for others
Usually none if viral!
155
What is tuberculosis?
= infectious disease caused by **mycobacterium spp**. with significant morbidity & mortality world wide
→ HIV linked!
156
Causative organisms (4) & spread?
Mycobacterium
* tuberculosis* = most common
* bovis* = unpasteurised milk
* africanum*
* microti*
*→ **aerosolised droplet** spread!*
but not all infected will develop active disease!
157
Nature of mycobacterium? Stain used?
aerobes, slow growing (15-20h)
Acid fast bacilli
= resistant to staining by acid
use **Ziehl-Neelsen stain**
= goes red / pink
158
People at risk of tuberculosis?
**Origin**
immigration (sub-saharan africa), hotspots
**immunosuppressed**
age
HIV
therapy (chemo etc)
* *IVDU, alcohol, smoking**
* *malnutrition, homeslessness**
159
Subtypes (manifestations) of TB?
**Primary TB**
= first infection with mycobacterium spp.
**Latent TB**
= immune system contains the nfection & cell mediated immunity memory developed to bac
**Reactivation TB / Post-primary TB**
= majority! dormant → active
= depression of host immune system (older, severe infection)
160
Pathophysiology of primary tuberculosis?
bac + macrophages → granuloma
**_= primary Ghon focus_**
as it grows → cavity in **_apex of lung_**
bac expelled when patient coughs
Primary focus in mediastinum lymph node = **_Ghon complex_**
161
Nature of the granuloma formed in TB?
Caseating granuloma
**on CXR: small calcified nodule,**
often on lower of upper lobe / upper of lower lobe
Can also be found in GI!
ileocaecal region
162
TB presentation?
**night sweats & weight loss**!
anorexia, low grade fever, malaise
cough 3/52
chest pain
breathlessness
haemoptysis
163
Investigations for TB?
**CXR**
patchy / nodular shadow in upper zone w/ loss of volume, fibrosis
normal in miliary TB
Sputum
**auramine-phenol fluorescent test**
= highlights bac as yellow-orange on a green background
**Ziehl-Neelsen stain** = red if TB
**Culture**
solid = Lowenstein-Jensen slopes / Middlebrook agar
**Nucleic acid amplication** = differentiate m. tb from others
**Lumber puncture & CSF exam**
= miliary TB
164
Testing for latent TB?
**Skin test = Mantoux test**
= cell mediated response to underskin TB antigen
→ **type 4 hypersensitivity reaction**
false neg if miliary / immunosuppressed
**Interferon gamma release assays (IGRAs)**
= more specific as can use specific antigen (diff bet vac and TB)
e.g. ESAT-6 & CFP10
165
Treatment for TB?
NOTIFIABLE to PUBLIC HEALTH ENGLAND + contact tracing
RIPE!!
**Rifampicin 6m**
**Isoniazid 6m**
**Pyrazinamide 2m**
**Ethambutol 2m**
166
Mechanism & SE Rifampicin?
bac cidal, anti protein synthesis
SE red urine, hepatitis
167
Mechanism & SE Isoniazid?
bac cidal, anti cell wall synthesis
SE hepatitis & neuropathy
168
Mechanism & SE Pyrazinamide?
bac cidal
SE hepatitis, arthralgia / gout + rash
169
Mechanism & SE Ethambutol?
bac static, anti cell wall synthesis
SE optic neuritis
170
Prevention for TB?
active case finding to reduce
**Vaccination**
**Bacillus Calmette–Guérin (BCG)**
= live attenuated, from M bovis
= in UK = mostly in areas with incidence bc ? cost effective
| (CXR for contact tracing)
171
What is respiratory failure?
Occurs when inadequate gas exchange in the lungs
→ ABG to sample
172
Types of respiratory failure & criteria?
**Type 1**
= hypoxaemia (PaO2 \< 8kPa)
normal / low Co2
**Type 2**
= hypoxaemia (PaO2 \< 8kPa)
hypercapnia (PaCO2 \> 6.5 kPa)
173
Causes of respiratory failure?
```
Hypoxaemia = V/Q mismatch
Hypercapnia = alveolar hypoventilation
```
reduced ventilation
increased dead space
diffusion limitation
174
What is the V/Q ratio?
V = ventilation
flow of air in and out of alveoli
Q = perfusion
flow of blood to alveolar capillaries
175
What does it mean to have / causes of a high V/Q ratio?
alveolae has poor perfusion
(compared to ventilation)
= vascular problem!
causes = e.g. pulm embolism
176
What does it mean to have / causes of a low V/Q ratio?
alveolar has poor ventilation
(compared to perfusion)
ventilation problem!
= hypoxaemia (low al O2 lvls)
causes = airway disease, interstitial lung disease → reduced ventilation
177
Causes of T1RF?
= hypoxaemia
pneumonia, pulm oedema
COPD, asthma
pneumothorax, **pulm embolism = MC!!**
178
Treatment for T1RF?
Usually responds well to oxygen therapy
179
Causes for T2RF?
→ hyperventilation
Exacerbation of obstructive lung disease
= COPD (most common)
asthma, cystic fibrosis, bronchiectasis
Respiratory depressants = opiate overdose
180
What should you not do for acute deterioration in COPD?
treat with high flow oxygen
→ can lead to oxygen induced hypercapnia
(from + V/Q mismatch & physiological dead space)
→ that's why **COPD / asthma O2 saturation target = 88-92%**
181
What is a pneumothorax?
Collection of air within the pleural space = space between parietal & visceral pleura
182
Types of pneumothorax?
**Spontaneous** = sans trauma
older with underlying lung disease
younger with apical blebs
**Traumatic**
can be open (communicate with outside air and pleural space) or closed
183
What is a pleural bleb?
a small collection of air in the pleural space \<1-2cm
184
Present - pneumothorax?
Sudden onset dyspnoea
Pleuritic chest pain!
Tachycardia
Reduced chest expansion
Diminished breath sounds
Hyper resonant to percussion
185
Investigations for pneumothorax?
CXR
186
Signs of tension pneumothorax?
tachycardia, tachypnoea
low O2 low BP
distended neck veins
_CXR_
Trachea deviated away from the affected side
187
Treatment for tension pneumothorax (& spontaneous pneumothorax)
**Needle aspiration** first
then **chest drain**
(for spont pneumothorax too)
| (at midclavicular line 2nd intercoastal space)
188
What is pleural effusion?
Abnormal collection of serous fluid within the pleural space
can also be: simple fluid, blood, pus (empyema)
189
Function of the pleural fluids?
Lubricate pleural surfaces
Generates surface tension
190
Pathophysiology - pleural effusion/
Imbalance of fluid entry & exit within the pleural space
**+ entry**: inflammation, pulmonary hypertension, nephrotic syndrome, cirrhosis
**- exit**: inflam mediators, damage (chemo), physical compression, decreased intrapleural pressure
191
Causes of pleural effusion?
**Transudate** = minimal protein & cellular content
→ **alteration in hydrostatic / oncotic pressure**
_Exudate_ = high protein & cellular content
→ _infection or malignancy_
192
Symptoms of pleural effusion?
Signs develop when \>300ml
Signs localised to side of effusion
reduced chest expansion & breath sounds
**stony dull percussion**
reduced vocal resonance
reduced tactile vocal fremitus (vibration of chest wall when speaking)
193
CXR signs of pleural effusion & criteria?
Need minimum 200-250 ml of fluid to detect
→ on PA chest xray!
= dense white consolidations!
aka opacification
meniscus at the costophrenic angle :)
194
Investigations for assessment of pleural effusion?
CXR to confirm
→ **Pleural tap (thoracentesis) & analysis**
needle inserted under anaesthesia
guide under ultrasound
→ sample for - pH, cytology, microbiology
**purulent in empyema**
turbid = infected
milky = lymph fluid
transudate / exudate based on **protein content**
(usually 🔪 30g/L)
195
Treatment for pleural effusions?
Exudate → drain
Transudate → TUC
**Pleurodesis** = injection that causes adhesions of visceral & parietal pleura → prevent reaccumulation of effusion = e.g. **tetracycline**
196
What is Goodpasture's syndrome?
Acute glomerulonephritis + pulmonary alveolar haemorrhage
presence of **circulating antibodies** against antigen in **basement membrane of kidney & lung**
197
Pathophysio & antibodies in Goodpasture's syndrome?
Autoimmune
= **type II antigen-antibody reaction** → diffuse pulm haemorrhage, glomerulonephritis ± AKI/CKD
antibody = anti-GBM antibodies
198
Risk & epidemiology of Goodpasture's syndrome?
adults (\>16)
rare in children
common in men
199
Presentation - Goodpasture's syndrome?
_Upper RI infect symptoms_
sneezing, nasal discharge, congest, runny nose + fever
* *Haemoptysis**
* *Acute glomerulonephritis**
Cough, tiredness
Anaemia
(from persistent intrapulmonary bleeding)
200
just for fun
if similar presentation to goodpasture's but no antibodies & kidney less involved, in children?
Idiopathic pulmonary haemosiderosis
201
Investigations & diagnosis for Goodpasture's?
Presence of anti-GBM antibodies in blood
CXR
transient patchy shadows / pulm infiltrates due to pulm haemorrhage
often in lower zone
Kidney biopsy
crescentic glomerulonephritis
202
Treatment for Goodpasture's?
→ in some may spontaneously improve
**Vigorous immunosuppresive** treatment
= corticosteroids = prednisolone
**Plasmaphoresis** = remove antibodies from blood and back
203
Complications - Goodpasture's
Renal failure
shock!
204
Some non-specific occupational lung disorders / complications?
Acute bronchitis / oedema!
Pulm fibrosis
Occupational asthma
Hypersensitivity pneumonitis
Bronchial carcinoma
205
What is coal worker's pneumoconiosis?
Pneumoconiosis = accumulation of dust in lungs & reaction of tissues to its presence
→ inhalation of coal dust particles in 15-20 years
206
Presentation & Management - coal worker's pneumoconiosis?
Asymptomatic mostly!
but High Res CT → round opacities in upper zone
avoid exposure to coal dust, claim compensation
207
What is silicosis? At risk populations?
Inhalation of silica particles (silica dioxide) = **toxic** to alveolar macrophages & **fibrogenic**
**at risk**: stonemasons / sand-blasters / pottery & ceramic workers / foundry workers
208
Presentation & management - silicosis?
Progressive dyspnoea & increased incidence of TB
avoid exp, claim compensation
209
Investigations & results - silicosis?
Potential PMH / current TB
**CXR**
diffuse nodular pattern in upper & midzone
thin streaks of calcification (egg-shell calcification) of the hilar zone
**Spirometry**
restrictive ventilatory defect
210
What is asbestosis? Who are at risk?
**Inhalation of asbestos** = banned now
widely used in roofing, insulation, fireproofing as resistant in heat & pH
mostly crocidolite (blue) = readily trapped in lung
211
Presentation - asbestosis?
**Progressive dyspnoea, finger clubbing, bilateral basal end inspiratory crackles**
+ risk pleural plaques and + risk mesothelioma & bronchial adenocarcinoma
212
Management for asbestosis?
only symptomatic manage
= corticosteroids
213
What is a (malignant) mesothelioma?
= tumour of the mesothelial cells of pleura
STRONGLY associated w/ ASBESTOS exposure
214
Aetiology & locations of mesotheliomas?
**men, 40-70's**
Exposure to asbestos = cause
but only 20% have **pulmonary** asbestosis
Other locations = **peritoneum, pericardium, testes**
215
Presentation - mesothelioma
**Severe chest pain**
* *Weight loss, finger clubbing**
* *recurrent pleural effusions** → malignancy!
Signs of mets = lymphadenopathy, hepatomegaly, bone pain / tenderness, abdominal pain / obstruction
| (invasion of chest wall possible → intercoastal nerves)
216
Diagnosis - mesothelioma
**CXR & CT**
= unilateral pleural effusion
= pleural thickening
**Pleural biopsy**
Bloody / straw coloured pleural fluid
217
Treatment - mesotheliomas
Surgery for extremely localised mesothelioma
Generally resistant to all surgery, chemo, radio
Poor prognosis :\<
218
Wegener's granulomatosis / Granulomatosis with polyangitis
- what is it?
Multisystem disorder characterised by granulomatous disease and vasculitis of small and medium cells
ANCA positive
219
Pathophysio of granulomatosis with polyangitis?
**Neutrophils activated inappropriately** by autoantibodies (Anti-neutrophil cytoplasmic antibodies ANCA) before tissue migration
→ neutrophil recruitment when there is _no_ infection → **granulomas & vasculitis**
220
Presentation of granulomatosis with polyangitis?
Lesions in upper respi tract, lungs & kidneys
**Severe rhinorrhea** (congested) & subsequent **mucosal ulceration** → **_characteristic saddle nose deform_**
cough, pleuritic pain, haemoptysis
skin purpura or nodules
PN, arthritis
renal disease → rapid progressive glomerulonephritis
221
Differential for granulomatosis with polyangitis -
Churg-Strauss syndrome - what is it? Features?
affects small arteries, male
rhinitis / asthma, eosinophilia, systemic vasculitis
high eosinophil count
ANCA positive
222
Investigations & diagnosis for granulomatosis with polyangitis?
**Bloods**
c-ANCA positive
+ PR3 antibodies
raised CRP, ESR
**CXR**
nodular masses or pneumonic infiltrates with cavitation = clear migratory pattern
**CT**
diffuse alveolar haemorrage
Urinalysis → proteinuria & haematuria → if pos: renal biopsy
223
Treatment for GPA?
Depends on extent of disease
Severe disease → steroids
Azathioprine / methotrexate for maintenance
224
Bronchial carcinoma - types?
Two main types
**Small cell lung carcinoma**
**Non SCLC** - in which
squamous carcinoma
adenocarcinoma
large cell and differentiated carcinoma
carcinoid tumours
225
Small cell carcinoma - risk factors & source & nature?
STRONGLY assoc **cigarette smoking**
arises from **endocrine cells**
central bronchus
secretes **polypeptide hormones**
226
Presentation, tx & prognosis, small cell lung carcinoma?
often arises in a central bronchus
early development of widespread metastases
**chemo** = primary tx
poor prognosis
227
Small cell lung tumours - supportive treatment?
```
**Primary = chemotherapy**
brachytherapy = radioactive source placed close to exams
```
**Pleuritic drain** - symptomatic relief
**Stents** for obstructions - **SVC**, **tracheal**
228
Small cell lung cancer - endocrine complications
= ectopic ADH, ACTH secretion
SIADH
Cushing's syndrome
(also Lambert Eaton)
229
Non - small cell carcinoma - tx?
Often treated best to **surgical oblation with lymph node sampling**
chemo /radio for follow up
More susceptible to new therapy e.g. tyrosine kinase
230
Lung cancer _most_ strongly associated with cigarette smoking?
Squamous cell carcinoma
231
Squamous cell carcinoma - nature & locations?
arise from **epithelial cells**
associated with **production of keratin**
**central tumours,** frequent central necrosis, loca spread
→ obstructive lesions of bronchus
→ late mets
232
What is a pancoast tumour?
Squamous cell carcinoma that start in the top part of the lung (the apex).
Associated with Horner's syndrome
233
Symptoms of a pancoast tumour?
**severe pain in the shoulder or the shoulder blade (scapula)**
**pain in the arm and weakness of the hand on the affected side**
**Horner's syndrome**
= flushing on one side of the face and that side doesn’t sweat. The eye on the same side has a smaller (constricted) pupil with a drooping or weak eyelid.
234
Most common lung cancer overall, also in non-smokers?
Adenocarcinoma
235
Nature of adenocarcinoma?
commonly associated w/ **asbestos**
arise from **mucus-secreting glandular cells**
central or peripheral
236
Features of adenocarcinoma?
Usually **single lesions** but may be multifocal / bilateral pattern
**Peripheral lesions** on CXR / CT
mets are common
237
Treatment for non-small cell lung cancer (80%)?
main = **Surgical excision** for peripheral tumours with no spread
**Chemo ± radio** = more advanced disease e.g. monoclonal antibodies
comp's = radiation pneumonitis, fibrosis
238
Main lung lymphoma - name, type of cells, tx?
**Baltoma**
= Bronchus Associated Tissue Lymphoma
B cell lymphoma
responds to **standard chemo** regimes
239
Name for benign tumours in the lung & nature?
Hamartomas
Irregular proliferation of benign tissue not normally found in lung tissue
240
Common destinations for lung mets? (LBAB)
Liver
Bone
Adrenal glands
Brain
241
Common origins of lung mets
| (causes of secondary lung cancer?)
Breast cancer
Bowel Cancer
**Kidney cancer = most common!!**
= renal cell carcinoma
Bladder cancer
242
Consequences of arterial thrombosis?
**Coronary circulation** = MI
**Cerebral circulation** = TIA / stroke
**Peripheral circulation** = peripheral vascular disease = claudication, rest pain, gangrene
243
STEMI ECG features?
ST elevation, tall T waves, LBBB, T wave inversion with pathological Q waves
244
Thrombolytic therapy for MI's?
Streptokinase & tissue plasminogen activator
245
Consequences of venous thrombosis?
Deep vein thrombosis = usually in legs
Pulmonary embolism = lungs
If atrial septal defect = travel to arterial system = stroke, MI, TIA
246
Risk of DVTs?
**Recent surgery**
**Genetics** = predisposition (**thrombophilias**)
_deficiencies_: factor V Leiden, protein C or S, antithrombin
**Acquired**
Antiphospholipid syndrome
Lupus anticoagulant
**Lifestyle**
Long haul flights, pregnancy, obesity, cancer, immobility, synthetic oestrogen
247
Main features of antiphospholipid syndrome?
CLOT
Clots = usually venous
Livedo reticularis = lace like rash on lower limbs
Obstetric loss
Thrombocytopenia
248
How might you provide venous thromboembolism prophylaxis
**Low molecular weight heparin**
CI existing warfarin / DOAC
**anti-embolic compression stockings**
CI peripheral arterial disease
249
DVT features?
Calf swelling and tenderness
Dilated superficial veins
Colour changes
Oedema
250
Investigations for DVT?
**_Well's score_** predicts risk of patient having DVT / PE
**D-Dime**r will _exclude_ DVT, as is also raised in pneumonia, heart failure, pregnancy etc
**Doppler ultrasound of the leg** = DIAGNOSTIC
repeat 6-8 days after if suggestive Wells & D-Dimer positive
251
Pulmonary embolism diagnostic test?
**CT Pulmonary angiogram CTPA**
= preferred
CI contrast allergy / kidney impairment
**Ventilation perfusion (VQ) scan** = alt
252
DVT initial management
**_Anticoagulation_**
= apixaban or rivaroxaban
if symptoms \< 14 days & symptomatic iliofemoral DVT
consider **_catheter directed thrombolysis_**
253
Long term anticoagulation - classes, indications & examples?
**Direct acting oral anticoagulants DOACs**
= apixaban, rivaroxaban, edoxaban & dabigatran
**Warfarin** = vitamin K antagonist
1st for antiphospholipid syndrome (+LMWH)
**Low Molecular Weight Heparin** LMWH
= Enoxaparin, dalteparin
1st in pregnancy
3m if reversible cause, \>3m if unclear, irreversible, recurrent. 3-6m active cancer
254
How might you reverse anticoagulation in strokes?
**Dabigatran** (direct thrombin inhibitor)
= idarucizumab
**rivaroxaban** / **apixaban** (direct factor Xa inhibitor)
= Andexanet alfa
**Warfarin** = vitamin K, human prothrombin complex (alt fresh frozen plasma)
255
Long term tx for VT if anticoag is unsuitable?
**_Inferior vena cava filters_**
= for recurrent PEs & those unsuitable for anticoag
= act as a sieve allow blood to flow through while catching clot
256
How might you investigate unprovoked DVT or PE
check for **antiphospholipid antibodies** (antiphospholipid syndrome)
check for **hereditary thrombophilia** if 1st degree relative also affected by DVT / OE
257
What is Budd-Chiari syndrome?
Blood clot develops in hepatic vein, blocking blood flow (assoc. hypercoagulable states)
→ causes **_acute hepatitis_**
→ **present**
abdominal pain
hepatomegaly
ascites
Phase 2A
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