Respiratory Flashcards

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)

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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

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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**
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4
Q

How are the results of spirometry expressed?

A

FEV1 / FVC

in %, best of three readings

Normal is >0.7

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5
Q

What does it mean to have an obstructive spirometry pattern?

A

FEV1/FVC below 0.7 = obstruction

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6
Q

What does it mean to have a restrictive spirometry pattern?

A

Normal FEV1/FVC > 0.7
but FVC is low = restriction

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7
Q

Name a few obstructive diseases?

A

COPD, asthma, emphysema, bronchiectasis, bronchiolitis,
cystic fibrosis

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8
Q

Name a few restrictive diseases?

A

Pulmonary
Pulm fibrosis, Pulm oedema, TB !

Non pulm
kyphoscoliosis, neuromuscular disease, connective tissue disease, obesity, pregnancy

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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

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10
Q

How might you assess reversibility?

A

Spirometry → Administer bronchodilator → repeat

Test with 400 microgram salbutamol

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11
Q

Compare and contrast asthma & COPD?

A

Asthma
variable airflow obstruction
reversible

COPD
fixed airflow obstruction
may be mixture

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12
Q

What is COPD?

A

Chronic Obstructive Pulmonary disease

persistent airflow limitation, not fully reversible

progressive, assoc chronic bronchitis & empysema

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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**
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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

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15
Q

Risk factors for COPD?

A

Cigarette smoke
Occupational exposure to pollutants, dust, chemicals, smoke

alpha-1 antitrypsin deficiency

recurrent lung infections

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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

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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

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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

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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

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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

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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

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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

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23
Q

How might you differentiate between asthma & COPD (in investigations)?

A

Repeat peak flow to exclude asthma

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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%

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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_!**
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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
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Treatment for pneumonia **H. influenza** nature of bac tx?
gram neg cocobacilli * *beta lactam** = amoxicillin, co-amoxiclav * *tetracyclines** = doxycycline NOT macrolides!!
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Treatment for pneumonia **S. aureus** nature of bac tx?
gram pos beta lactams = flucloxacillin, cefuroxime if MRSA = vancomycin, linezolid
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Treatment for pneumonia **Klebsiella pneumonia** nature of bac tx?
gram neg, entero beta lactam = co-amoxiclav, cephalosporins
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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
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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
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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
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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
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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
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Treatment for empyema / complicated parapneumonic effusions?
**Drainage** - chest tube / cardiothoracici surgery **Antimicrobials** co-amoxiclav meropenam for anaerobic coverage
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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**
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Causative organisms & nature - lung abscess?
**Strep milleri** = alpha haemolytic optochin resistant **Klebsiella pneumonia** & other gram neg bac **Anaerobes!!!** ensure microbio coverage
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Treatment for lung abscess?
= prolonged antibiotics for 6 weeks +, surgical drainage if required
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Hospital acquired pneumonia - criteria? signs?
Acquired at least 48 hours after hospital admission new fever, purulent secretions, new radiological infiltrates / CRP increase, + O2 requirements
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Hospital acquired pneumonia - causative organisms?
**S. aureus** (& MRSA) strongly ventilator associated **Pseudomonas aeruginosa** * *Acinetobacter baumanii** * *Klebsiella pneumoniae** * *E. coli**
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Treatment for early onset hospital acquired pneumonia (CAP organisms)
Metronidazole Beta lactams with inhibitor of beta lactamase = co-amoxiclav, piperacillin-tazobactam
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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
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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
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Signs & causes of bronchitis?
cough, often wheeze \> 5 days ± phlegm no fever / signs of infection! majority viral, rarely bacterial in healthy adults
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Investigate & treatment, bronchitis?
* *CXR** - normal * *Viral & bacterial throat swabs** = PCR for resp viruses & mycoplasma, culture for others Usually none if viral!
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What is tuberculosis?
= infectious disease caused by **mycobacterium spp**. with significant morbidity & mortality world wide → HIV linked!
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Causative organisms (4) & spread?
Mycobacterium * tuberculosis* = most common * bovis* = unpasteurised milk * africanum* * microti* *→ **aerosolised droplet** spread!* but not all infected will develop active disease!
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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
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People at risk of tuberculosis?
**Origin** immigration (sub-saharan africa), hotspots **immunosuppressed** age HIV therapy (chemo etc) * *IVDU, alcohol, smoking** * *malnutrition, homeslessness**
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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)
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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_**
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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
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TB presentation?
**night sweats & weight loss**! anorexia, low grade fever, malaise cough 3/52 chest pain breathlessness haemoptysis
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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
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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
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Treatment for TB?
NOTIFIABLE to PUBLIC HEALTH ENGLAND + contact tracing RIPE!! **Rifampicin 6m** **Isoniazid 6m** **Pyrazinamide 2m** **Ethambutol 2m**
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Mechanism & SE Rifampicin?
bac cidal, anti protein synthesis SE red urine, hepatitis
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Mechanism & SE Isoniazid?
bac cidal, anti cell wall synthesis SE hepatitis & neuropathy
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Mechanism & SE Pyrazinamide?
bac cidal SE hepatitis, arthralgia / gout + rash
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Mechanism & SE Ethambutol?
bac static, anti cell wall synthesis SE optic neuritis
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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)
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What is respiratory failure?
Occurs when inadequate gas exchange in the lungs → ABG to sample
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Types of respiratory failure & criteria?
**Type 1** = hypoxaemia (PaO2 \< 8kPa) normal / low Co2 **Type 2** = hypoxaemia (PaO2 \< 8kPa) hypercapnia (PaCO2 \> 6.5 kPa)
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Causes of respiratory failure?
``` Hypoxaemia = V/Q mismatch Hypercapnia = alveolar hypoventilation ``` reduced ventilation increased dead space diffusion limitation
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What is the V/Q ratio?
V = ventilation flow of air in and out of alveoli Q = perfusion flow of blood to alveolar capillaries
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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
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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
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Causes of T1RF?
= hypoxaemia pneumonia, pulm oedema COPD, asthma pneumothorax, **pulm embolism = MC!!**
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Treatment for T1RF?
Usually responds well to oxygen therapy
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Causes for T2RF?
→ hyperventilation Exacerbation of obstructive lung disease = COPD (most common) asthma, cystic fibrosis, bronchiectasis Respiratory depressants = opiate overdose
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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%**
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What is a pneumothorax?
Collection of air within the pleural space = space between parietal & visceral pleura
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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
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What is a pleural bleb?
a small collection of air in the pleural space \<1-2cm
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Present - pneumothorax?
Sudden onset dyspnoea Pleuritic chest pain! Tachycardia Reduced chest expansion Diminished breath sounds Hyper resonant to percussion
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Investigations for pneumothorax?
CXR
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Signs of tension pneumothorax?
tachycardia, tachypnoea low O2 low BP distended neck veins _CXR_ Trachea deviated away from the affected side
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Treatment for tension pneumothorax (& spontaneous pneumothorax)
**Needle aspiration** first then **chest drain** (for spont pneumothorax too) | (at midclavicular line 2nd intercoastal space)
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What is pleural effusion?
Abnormal collection of serous fluid within the pleural space can also be: simple fluid, blood, pus (empyema)
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Function of the pleural fluids?
Lubricate pleural surfaces Generates surface tension
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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
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Causes of pleural effusion?
**Transudate** = minimal protein & cellular content → **alteration in hydrostatic / oncotic pressure** _Exudate_ = high protein & cellular content → _infection or malignancy_
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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)
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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 :)
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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**
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What is Goodpasture's syndrome?
Acute glomerulonephritis + pulmonary alveolar haemorrhage presence of **circulating antibodies** against antigen in **basement membrane of kidney & lung**
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Pathophysio & antibodies in Goodpasture's syndrome?
Autoimmune = **type II antigen-antibody reaction** → diffuse pulm haemorrhage, glomerulonephritis ± AKI/CKD antibody = anti-GBM antibodies
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Risk & epidemiology of Goodpasture's syndrome?
adults (\>16) rare in children common in men
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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)
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just for fun if similar presentation to goodpasture's but no antibodies & kidney less involved, in children?
Idiopathic pulmonary haemosiderosis
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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
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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!
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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
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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
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Presentation & management - silicosis?
Progressive dyspnoea & increased incidence of TB avoid exp, claim compensation
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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
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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
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Presentation - asbestosis?
**Progressive dyspnoea, finger clubbing, bilateral basal end inspiratory crackles** + risk pleural plaques and + risk mesothelioma & bronchial adenocarcinoma
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Management for asbestosis?
only symptomatic manage = corticosteroids
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What is a (malignant) mesothelioma?
= tumour of the mesothelial cells of pleura STRONGLY associated w/ ASBESTOS exposure
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Aetiology & locations of mesotheliomas?
**men, 40-70's** Exposure to asbestos = cause but only 20% have **pulmonary** asbestosis Other locations = **peritoneum, pericardium, testes**
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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)
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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 :\<
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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
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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