Respiratory Flashcards
1
Q
Most common infective cause of COPD exacerbation?
A
Haemophilus influenzae
2
Q
What are some infective causes of COPD exacerbation?
A
- haemophilus influenzae
- streptococcus pneumoniae
- moraxella catarrhalis
- haemophilus parainfluenzae
- pseudomonas aeruginosa
3
Q
Signs of a life-threatening asthma attack?
A
- SpO2 < 92%
- PEFR < 33%
- silent chest
- poor respiratory effort
- altered consciousness
- confusion / agitation
- exhaustion
- cyanosis
4
Q
What are some side effects of salbutamol?
A
- arrhythmias
- headache
- palpitations
- tremor
- hyperglycaemia
- hypokalaemia (with high doses)
5
Q
Most common lung cancer in non-smokers?
A
Adenocarcinoma
6
Q
What is the CURB65 score?
A
- Confusion
- Urea > 7 mmol/L
- Respiratory rate > 30
- Blood pressure (systolic < 90 or diastolic < 60)
- age > 65
7
Q
What is the dyspnoea scale used for COPD?
A
Medical Research Council dyspnoea scale.
8
Q
Grade 1 MRC dyspnoea scale?
A
Not troubled by breathlessness except on vigorous exertion.
9
Q
Grade 2 MRC dyspnoea scale?
A
Short of breath when hurrying / walking up inclines.
10
Q
Grade 3 MRC dyspnoea scale?
A
Walks slower than contemporaries because of breathlessness, or has to stop for breath when walking at own pace.
11
Q
Grade 4 MRC dyspnoea scale?
A
Stops for breath after walking about 100m or stops after a few minutes’ walking on level ground.
12
Q
Grade 5 MRC dyspnoea scale?
A
Too breathless to leave the house / breathless on dressing or undressing.
13
Q
Second line COPD medication?
A
LABA
14
Q
What is COPD?
A
Progressive obstructive airway disease that is not fully reversible. Results from disease of the airways and lung parenchyma (chronic bronchitis and emphysema).
15
Q
What is meant by emphysema?
A
Damage to alveoli resulting in the rupture of alveolar walls. This creates large airspaces instead of many small ones.
16
Q
Causes of COPD?
A
- smoking
- occupational exposures (coal dust)
- alpha 1 antitrypsin deficiency
17
Q
Risk factors for COPD?
A
- smoking
- older age
- occupational exposure to dust, chemicals, etc
- alpha 1 antitrypsin deficiency
- air pollution exposure
18
Q
Pathophysiology of chronic bronchitis?
A
- chronic inflammation and fibrosis of the bronchi and bronchioles
- neutrophil, T lymphocyte, and macrophage infiltration
- leads to goblet cell hyperplasia, mucus hypersecretion, narrowing of small airways
19
Q
Pathophysiology of emphysema?
A
- inflammatory cells such as macrophages and neutrophils produce proteases (e.g. elastase)
- elastase destroys elastin (important for the structural integrity of the alveoli)
- alveoli become prone to collapse, and there is alveolar dilatation (may join neighbouring alveoli to form bullae)
20
Q
How does COPD lead to cor pulmonale?
A
- chronic hypoxia causes pulmonary artery vasoconstriction
- chronic elevation of pulmonary arterial pressure results in right heart failure
21
Q
Signs and symptoms of COPD?
A
- chronic productive cough
- dyspnoea
- sputum production
- wheeze
- pursed lip breathing
- barrel chest
- coarse crackles on auscultation
22
Q
Why do COPD patients show pursed lip breathing?
A
Attempt to prevent alveolar collapse by increasing end expiratory pressure.
23
Q
Signs of acute COPD exacerbation?
A
- worsening dyspnoea and cough
- increased sputum production or a change in sputum colour
- pyrexia
- signs of CO2 retention - flapping tremor and asterixis
- accessory muscle use
24
Q
What are signs of CO2 retention?
A
- asterixis
- flapping tremor
- confusion
- headache
25
Investigations for COPD?
- spirometry with reversibility testing
- CXR
- sputum culture
- ECG / echocardiogram if cor pulmonale suspected
- serum A1AT
26
What does spirometry show in COPD?
- normal / reduced FVC
- reduced FEV1
- FEV1 / FVC less than 70%
No / little reversibility.
27
Differentials for COPD?
- asthma
- congestive heart failure
- bronchiectasis
- lung cancer
- tuberculosis
28
Non-pharmacological management of COPD?
- smoking cessation
- inhaler technique
- influenza and pneumococcal vaccinations
- pulmonary rehabilitation
- long term oxygen therapy if appropriate
29
Pharmacological management of COPD?
1. SABA (salbutamol) / SAMA (ipratropium)
2. LABA and LAMA / ICS (if responsive)
3. LABA, LAMA, ICS
30
Example of inhaled corticosteroid?
- fluticasone
| - beclomethasone
31
Medication for excessive sputum production?
Mucolytics (e.g. carbocisteine).
32
Surgical options for COPD?
- bullectomy
| - lung transplantation
33
Management of acute COPD exacerbation?
- oxygen to 88-92% (Venturi mask for specific concentration)
- salbutamol / ipratropium nebulisers
- oral / IV corticosteroids
- antibiotics
34
What antibiotics are used in acute COPD exacerbation?
- doxycycline
| - co-amoxiclav
35
When is IV aminophylline / theophylline indicated in COPD?
Severe acute exacerbation - not first line.
36
What is asthma?
Chronic inflammatory condition of the airways, causing episodic exacerbations of bronchoconstriction.
37
What type of hypersensitivity reaction is allergic asthma?
Type 1 (IgE mediated).
38
What type of respiratory failure occurs in COPD?
Type 2 (low oxygen, high CO2).
39
What is meant by brittle asthma?
Asthma that worsens suddenly or severely, characterised by wide variation of PEFR despite high doses of steroids.
40
What are the two types of asthma?
- eosinophilic (allergic)
| - non-eosinophilic
41
What is atopy?
Genetic predisposition to allergic asthma, atopic dermatitis, allergic rhinitis.
42
What is Samter's triad?
Aspirin-exacerbated respiratory disease:
- asthma
- aspirin sensitivity
- nasal polyps
43
Risk factors for asthma?
- smoking / smoking exposure
- premature birth and low birth weight
- family Hx of atopy
- occupational exposure (dust, flour)
- low socioeconomic status
44
Pathophysiology of asthma?
- inhalation of allergens results in a type 1 hypersensitivity reaction in the airways
- sensitisation results in the release of IgE antibodies from plasma cells, which bind to mast cell receptors
- subsequent antigen exposure causes mast cell degranulation and histamine release, causing smooth muscle contraction, bronchoconstriciton, and inflammation
- following the initial reaction, inflammatory cell recruitment occurs
- fibrosis and airway remodelling eventually occur in response to chronic inflammation
45
Signs and symptoms of asthma?
- dry cough
- dyspnoea
- expiratory wheeze
- chest tightness
- poor sleep / nocturnal symptoms
46
Provoking factors for an asthma attack?
- allergens
- infection
- exercise
- cold air
47
PEFR in life threatening asthma attack?
less than 33% of normal
48
Signs and symptoms of severe vs life threatening asthma attack?
Severe - can't complete sentences due to worsening symptoms.
| Life-threatening - silent chest, cyanosis, exhaustion, confusion, poor respiratory effort.
49
Investigations for asthma?
- spirometry (with reversibility testing)
- PEFR diary
- immunoassay for allergen-specific IgE
- CXR - normal or hyperinflated
50
Spirometry results in asthma?
- FVC normal or reduced
- FEV1 reduced
- FEV1 / FVC less than 70%
Asthma shows reversibility with bronchodilators.
51
Side effect of high doses of salbutamol?
Hypokalaemia
52
Acute management of severe asthma attack?
- oxygen (target 94-98%)
- salbutamol nebulisers
- ipratropium nebulisers
- IV hydrocortisone
53
Non-pharmacological management of asthma?
- inhaler technique
| - identify and avoid triggers
54
Pharmacological management of asthma?
1. salbutamol (SABA)
2. ICS (beclamethasone)
3. LABA
4. increase dose of ICS or leukotriene receptor antagonist
55
Example of leukotriene receptor antagonist?
Montelukast
56
Example of LABA?
Salmeterol
57
Side effects of ICS?
- hoarse voice
- sore throat
- oral candidiasis
58
What is MART?
Maintenance and reliever therapy - combined corticosteroid and bronchodilator inhaler.
59
Common types of inhaler?
- metered dose inhaler
| - dry powder inhaler
60
Complications of asthma?
- pneumonia
- respiratory failure
- pneumothorax
- fatigue
61
What proportion of primary lung cancer is small cell lung cancer?
15-20%
62
What is small cell lung cancer?
- high grade, neuroendocrine tumour
| - associated with paraneoplastic syndromes
63
What are the three types of non-small cell lung cancer?
- adenocarcinoma
- squamous cell carcinoma
- large cell lung cancer
64
Most common lung cancer?
Adenocarcinoma
65
Where in the lung does adenocarcinoma occur?
Peripheries
66
Where in the lung does squamous cell carcinoma occur?
Central parts
67
Characteristics of large cell lung cancer?
- undifferentiated
| - metastasises early
68
T1 lung cancer?
Tumour is less than 3cm and surrounded by the lung / visceral pleura. No involvement of the main bronchus.
69
T2 lung cancer?
Tumour is 3-5cm OR involves main bronchus (not carina) / invasion of visceral pleura.
70
T3 lung cancer?
Tumour is 5-7cm OR involves the chest wall, pericardium, phrenic nerve, or satellite nodules (accessory foci) in the same lobe.
71
T4 lung cancer?
Tumour > 7cm OR invades the mediastinum, diaphragm, heart, great vessels, carina / trachea, oesophagus OR separate tumour in different lobe of the same lung.
72
Which lung cancers is asbestos exposure associated with?
- mesothelioma
| - adenocarcinoma
73
Most common lung cancer in smokers?
Squamous cell
74
Most common lung cancer in non-smokers?
Adenocarcinoma
75
Clinical presentation of lung cancer?
- cough
- malaise
- weight loss
- haemoptysis
- lymphadenopathy
76
Investigations for lung cancer?
- CXR
- CT thorax and abdomen
- bronchoscopic biopsy
77
Management of lung cancer?
- smoking cessation
- surgical resection
- radiotherapy
- chemotherapy
- palliative care
78
Common sites of lung cancer metastasis?
- bones
- brain
- liver
- adrenal glands
79
Paraneoplastic syndromes associated with small cell lung cancer?
- hypercalcaemia
- SIADH
- Lambert-Eaton syndrome
80
What is mesothelioma?
Lung malignancy affecting the mesothelial cells of the pleura. Caused by asbestos inhalation.
81
What is a pulmonary embolism?
Occlusion / obstruction of the pulmonary artery or one of its branches.
82
What is meant by a non-massive PE?
Haemodynamically stable with no evidence of right heart strain.
83
What is meant by sub-massive PE?
Haemodynamically stable with evidence of right heart strain.
84
What is meant by massive PE?
Haemodynamic instability due to right heart strain / failure.
85
Typical cause of PE?
Embolus arising from DVT.
86
Pathophysiology of PE?
- occlusion of one of the pulmonary arteries leads to absence of perfusion to that area of the lung
- V/Q mismatch leads to hypoxia and breathlessness
- V/Q mismatch may also cause elevated pulmonary arterial pressure, resulting in acute right heart failure
87
Why does infarction usually not occur in PE?
Prevented by the bronchial circulation.
88
Classic presentation of PE?
New onset shortness of breath, pleuritic chest pain, features of DVT.
89
Signs and symptoms of PE?
- new onset shortness of breath
- pleuritic chest pain
- features of DVT
- cough
- haemoptysis
- low grade fever
- tachycardia
- syncope / dizziness
90
Signs of right heart failure?
- hypotension
- raised JVP
- tricuspid regurgitation (pan-systolic murmur)
91
Scoring system for PE?
Wells score:
- greater than 4 means PE is likely
- 4 or less means PE is unlikely
92
Gold standard investigation for PE?
CT pulmonary angiography
93
ECG changes in PE?
- sinus tachycardia most common finding
| - S1Q3T3 (acute right heart failure): deep S wave, Q wave, T wave inversion
94
What is the PESI score?
Pulmonary embolism severity index - predicts 30 day outcome of patients with confirmed PE.
95
Investigations to assess right heart strain in PE?
- troponin
- ECG
- echocardiography
96
Empirical anticoagulation for suspected PE?
LMWH
97
First line anticoagulation for confirmed PE?
apixaban / rivaroxaban
98
Second line anticoagulation for confirmed PE?
LMWH
99
When would you use thrombolysis for PE?
First line for massive PE.
100
Long term management of PE?
Continue anticoagulation for 3 months.
101
What is meant by latent TB?
TB infection is suppressed, there is no active disease.
102
Cause of TB?
Mycobacterium complex:
- mycobacterium tuberculosis
- mycobacterium bovis
103
Characteristics of mycobacterium tuberculosis?
- aerobic
- acid-fast
- slow-growing
104
How is TB spread?
Aerosolised droplets
105
Risk factors for TB?
- travel to an endemic country
| - immunosuppression
106
Pathophysiology of TB?
- alveolar macrophages engulf the bacilli, but they survive and multiply within the macrophages
- subsequent macrophage death and lysis releases the bacilli
- immune response results in clearance, suppression, or progression to primary disease if inadequate
- Th1 cells form caseating granulomas with macrophages, to contain the bacilli (latent TB)
107
Why might latent TB become reactivated?
- immunodeficiency (HIV)
| - immunosuppressive drugs (infliximab)
108
What is the Ghon focus?
Primary TB lesion - caseating granuloma.
109
What is the Ghon complex?
Ghon focus with ipsilateral mediastinal lymph node involvement.
110
What is a Ranke complex?
Calcified Ghon complex.
111
Signs and symptoms of pulmonary TB?
- cough
- fever
- weight loss
- malaise
- dyspnoea
- haemoptysis
112
What is miliary TB?
Disseminated haematogenous spread, leading to multiple organ failure.
113
Options for TB screening?
- mantoux test
| - interferon gamma release assay
114
What is the Mantoux test?
- intradermal injection of tuberculin
- type IV hypersensitivity reaction indicates latent TB
- results affected by the BCG vaccine
115
What is the interferon gamma release assay?
Tests for T-cell interferon game response to mycobacterium tuberculosis antigen. Unaffected by previous BCG vaccine.
116
Investigations for TB?
- sputum samples x3 for microscopy and culture
| - CXR
117
CXR findings in TB?
- consolidation
- cavitation (usually upper lobe)
- effusion
118
What type of vaccine is the BCG vaccine?
Live attenuated vaccine.
119
Management of TB
- isoniazid
- rifampicin
- pyrazinamide
- ethambutol
120
How does isoniazid work?
Inhibits mycolic acid synthesis - cell wall component of M. tuberculosis.
121
Side effects of isoniazid?
- polyneuropathy
| - hepatotoxicity
122
How does rifampicin work?
Inhibits RNA polymerase.
123
Side effects of rifampicin?
- red / orange staining of secretions
| - hepatotoxicity
124
Side effects of pyrazinamide?
- hepatotoxicity
| - gout
125
How does ethambutol work?
Inhibits an enzyme needed for cell wall synthesis.
126
Side effects of ethambutol?
Optic neuritis
127
What is pneumonia?
Infection of the lung parenchyma, causing inflammation.
128
What is hospital-acquired pneumonia?
Pneumonia presenting > 48 hours after hospital admission (not incubating at the time of admission).
129
Causes of typical CAP?
- streptococcus pneumoniae
- moraxella catarrhalis
- haemophilus influenzae
130
Non-zoonotic causes of atypical CAP?
- legionella pneumophila
- mycoplasma pneumoniae
- chlamydophila pneumoniae
131
Zoonotic causes of atypical CAP?
- coxiella burnetii
| - chlamydia psittaci
132
Causes of HAP?
- staph aureus
| - pseudomonas aeruginosa
133
Fungal pathogens causing pneumonia?
Seen in immunocompromised patients:
- aspergillus fumigatus
- pneumocystis jirovecii
134
Risk factors for pneumonia?
- age > 65
- residence in healthcare setting
- COPD
- immunocompromised
- intubation and ventilation
135
Signs and symptoms of pneumonia?
- cough
- dyspnoea
- fever
- purulent sputum
- pleuritic pain
- confusion
- dull percussion
- coarse crepitations
136
SIADH indicates what cause of pneumonia?
Legionella pneumophila
137
What is the CURB65 score?
- confusion
- urea > 7
- respiratory rate >30
- BP < 90 systolic or < 60 diastolic
- over 65
138
Management setting according to CURB65 score?
0-1 : outpatient
2: inpatient
3-5: HDU / ICU
139
Complications of pneumonia?
- parapneumonic effusion
- pneumothorax
- abscess
- empyema
- sepsis
140
Investigations for pneumonia?
- sputum cultures
- blood cultures
- CXR (consolidation, parapneumonic effusion, etc)
141
Summary of pneumonia management?
- oxygen titrated to saturations
- IV / oral fluids
- analgesia
- antibiotics
142
Antibiotics for mild CAP?
oral amoxicillin or doxycycline (if allergic)
143
Antibiotics for severe CAP?
IV co-amoxiclav + clarithromycin
144
Antibiotics for mild HAP?
Oral co-amoxiclav
145
Antibiotics for severe HAP?
IV piperacillin / tazobactam
146
Antibiotics for atypical pneumonia?
Does not respond to penicillins.
| Clarithromycin / doxycycline.
147
Treatment for fungal pneumonia?
Co-trimoxazole (trimethoprim and sulfamethoxazole).
148
What is idiopathic pulmonary fibrosis?
Chronic condition characterised by progressive lung fibrosis of unknown aetiology.
149
Signs and symptoms of idiopathic pulmonary fibrosis?
- exertional dyspnoea
- dry cough
- fatigue
- bilateral inspiratory crackles
- clubbing
150
Investigations for idiopathic pulmonary fibrosis?
- spirometry
- DLCO (diffusing capacity for carbon monoxide)
- CXR
- high-resolution CT
- transbronchial biopsy
151
Spirometry results in idiopathic pulmonary fibrosis?
Restrictive pattern:
- reduced FEV1
- reduced FVC
- normal FEV1 / FVC ratio
152
CT findings in idiopathic pulmonary fibrosis?
- honeycombing
| - traction bronchiectasis
153
Management of idiopathic pulmonary fibrosis?
- smoking cessation
- pulmonary rehabilitation
- oxygen therapy
- biological therapies
- lung transplant
154
What biological therapies can be used for idiopathic pulmonary fibrosis?
Pirfenidone - anti-inflammatory and anti-fibrotic.
| Nintedanib - acts on growth factor receptors (VEGF) implicated in IPF pathogenesis.
155
What is sarcoidosis?
Multi-system granulomatous disorder, most commonly affecting the lungs.
156
Typical sarcoidosis patient?
Black female aged 20-40 with progressive breathlessness, lymphadenopathy, and fatigue.
157
Pathophysiology of sarcoidosis?
Non-caseating granulomas form - aggregations of macrophages with multi-nucleated giant cells in the centre, and scattered CD4 T lymphocytes.
Advanced pulmonary sarcoidosis leads to fibrosis.
158
Systemic / pulmonary manifestations of sarcoidosis?
- fatigue
- lymphadenopathy
- progressive breathlessness
- wheezing
- inspiratory creptitations
- clubbing
159
Extra-pulmonary manifestations of sarcoidosis?
- liver nodules & cirrhosis
- eye involvement (uveitis)
- erythema nodosum / papular sarcoidosis
- cardiomyopathy
- renal disease
160
What is Lofgren's syndrome?
Acute variant of sarcoidosis:
- bilateral hilar lymphadenopathy
- erythema nodosum
- arthralgia
- fever
161
Skin manifestations of sarcoidosis?
- erythema nodosum
- papular sarcoidosis
- lupus pernio (nodular purple rash over nose and cheeks)
162
Investigations for sarcoidosis?
- spirometry
- serum ACE (elevated)
- CXR (lymphadenopathy)
- high-resolution CT
- transbronchial biopsy / bronchoalveolar lavage
- ECG / echocardiography for cardiac involvement
163
Spirometry results in sarcoidosis?
Restrictive pattern:
- reduced FEV1
- reduced FVC
- normal FEV1 / FVC ratio
164
Differentials for sarcoidosis?
- tuberculosis
- lymphoma
- hypersensitivity pneumonitis
165
Management of sarcoidosis?
- steroids with bone protection
- methotrexate / azathioprine
- anti-TNF agents (infliximab)
- lung transplant
166
Prognosis for sarcoidosis?
Many patients experience spontaneous resolution within 6 months.
167
What is bronchiectasis?
Obstructive lung disease characterised by irreversible abnormal dilatation of the airways. Often due to recurrent / severe infections.
168
Infections that can lead to bronchiectasis?
- mycobacterium tuberculosis
- pseudomonas aeruginosa
- streptococcus pneumoniae
- haemophilus influenzae
- aspergillus fumigatus
169
Causes of bronchiectasis?
- post-infectious
- genetic disorder (CF, A1AT deficiency, primary ciliary dyskinesia)
- COPD & asthma
- connective tissue disorders
- idiopathic
170
Pathophysiology of bronchiectasis?
- micro-organisms colonising the airways leads to chronic inflammation
- this results in bronchial wall oedema and increased mucus production
- recruitment of inflammatory cells and cytokine release leads to progressive airway destruction and dilatation
171
Vicious cycle of bronchiectasis?
Bronchial damage makes patients more susceptible to subsequent airway colonisation.
172
Signs and symptoms of bronchiectasis?
- persistent sputum production
- persistent cough
- dyspnoea
- fever
- fatigue
- lung crepitations
- clubbing
- wheeze
173
Investigations for bronchiectasis?
- blood cultures
- sputum cultures
- genetic testing (e.g. CFTR mutation, SERPINA1 mutation)
- thin section CT (signet ring sign)
- spirometry (obstructive pattern)
174
What is the signet ring sign?
Sign of bronciectasis on thin section CT.
| Cross section of dilated bronchus with its accompanying pulmonary artery branch.
175
Management of bronchiectasis?
- annual flu vaccine
- physiotherapy for airway clearance
- mucolytics (oral carbocisteine)
- prophylactic antibiotics / antibiotics for acute exacerbation
- bronchodilators
- lung transplant
176
What is cystic fibrosis?
Autosomal recessive multisystem disease caused by mutations in the CFTR gene.
177
Aetiology of CF?
Mutations in CFTR gene on chromosome 7.
178
Pathophysiology of CF?
- mutations in the CFTR gene result in misfolded CFTR channel
- this leads to impaired chloride ion transport, resulting in the production of thick mucus
179
Most commonly identified CFTR mutation?
Delta-F508
180
Common colonising organisms in children with CF?
- staph aureus
| - haemophilus influenzae
181
Common colonising organisms in adults with CF?
pseudomonas aeruginosa
182
Why does CF cause lung disease?
- production of thick sticky mucus results in reduced clearance and airway obstruction
- increases susceptibility to infection
- leads to chronic bronchial damage and bronchiectasis
183
Why does CF cause GI disease?
- thick secretions impair biliary and pancreatic drainage
| - pancreatic islets may also be damaged (diabetes mellitus)
184
Clinical presentation of CF in neonates?
- failure to pass meconium
- failure to thrive
- wet-sounding cough
185
Signs and symptoms of CF?
- wet-sounding cough
- steatorrhoea
- malabsorption
- recurrent lower respiratory tract infections
- clubbing
- nasal polyps
186
What is the screening test for CF?
Immuno-reactive trypsin test (newborn heel prick test). Positive result indicates CF as IRT is produced due to CF-related pancreatic damage.
187
Investigations for CF?
- pilocarpine-induced sweat test (chloride > 60 mmol/L)
| - genetic testing
188
Management of CF?
- vaccinations
- airway clearance techniques
- pancreatic enzyme replacement
- nebulised DNase (mucoactive agent)
- antibiotics
- oxygen therapy
- lung transplant
- CFTR modulators
189
What are CFTR modulators?
- tezacaftor and elexacaftor - increase amount of CFTR delivered to the cell surface
- ivacaftor - facilitates CFTR channel opening
190
Complications of CF?
- recurrent pancreatitis
- small bowel obstruction
- pneumothorax
- diabetes mellitus
- cor pulmonale
191
Why does pseudomonas colonisation increase morbidity and mortality in CF patients?
- bacteria can form biofilms
| - often become resistant to multiple antibiotics
192
What is a pleural effusion?
Abnormal collection of fluid in the pleural space.
193
What is a transudate?
Fluid has minimal protein content.
194
What causes transudative pleural effusion?
Ultrafiltration due to changes in hydrostatic / oncotic pressure.
- heart failure
- hypoalbuminaemia
- cirrhosis
- nephrotic syndrome
195
What is an exudate?
Fluid has high protein content.
196
What causes exudative pleural effusion?
Inflammatory conditions affecting vessel permeability or lymphatic drainage.
- infection (parapneumonic effusion, TB)
- malignancy (breast / lung)
197
Signs and symptoms of pleural effusion?
- breathlessness
- non-productive cough
- pleuritic chest pain
- reduced chest expansion
- reduced breath sounds
- stony dull percussion
198
Investigations for pleural effusion?
- pleural paracentesis
- CXR
- ultrasound
199
Gold standard investigation for pleural effusion?
Pleural paracentesis - greater than 30g/L is an exudate.
200
Management of pleural effusion?
- address underlying cause
- therapeutic paracentesis / chest drain
- antibiotics (parapneumonic / empyema)
- pleurodesis
201
What is pleurodesis?
Procedure to induce pleural inflammation and fibrosis with a chemical sclerosant or manual abrasion.
Indicated if effusion if malignant / recurrent.
202
What is a pneumothorax?
Collection of air in the pleural space.
203
What is a tension pneumothorax?
One way valve system allows air into the inter-pleural space but does not let it escape. Results in increasing pressure, impaired venous return to the heart, and compromised cardiac output.
204
Causes of pneumothorax?
- trauma
- primary spontaneous
- secondary spontaneous (COPD, asthma)
205
Cause of spontaneous pneumothorax?
Ruptured apical bleb / bullae.
206
Clinical presentation of pneumothorax?
Sudden onset of (typically unilateral) pleuritic chest pain and dyspnoea.
207
Signs of pneumothorax?
- tracheal deviation
- reduced chest expansion
- reduced breath sounds
- hyper-resonant percussion
208
How does tension pneumothorax present?
Severe respiratory distress / haemodynamic instability.
209
First line investigation for pneumothorax?
- erect CXR
| - CT / ultrasound if patient unable to sit upright
210
What is considered a large pneumothorax?
> 2cm between chest wall and lung margin (at level of the hilum)
211
Gold standard investigation for pneumothorax?
CT chest
212
Management of tension pneumothorax?
- urgent decompression - large bore cannula in the 2nd intercostal space at the mid-clavicular line
- place chest drain
- high flow O2
213
Management of large / symptomatic spontaneous pneumothorax?
- needle aspiration (14-16G)
| - small bore Seldinger chest drain (< 14F) if secondary or needle aspiration ineffective
214
Management of small, asymptomatic spontaneous pneumothorax?
Observation and outpatient follow-up.
215
Indications for pleurodesis for a pneumothorax?
- pilot
- bilateral pneumothoraces
- persistent pneumothorax
216
What is pulmonary hypertension?
Increased pressure in pulmonary arteries leading to right sided heart strain and systemic venous congestion.
217
Causes of pulmonary hypertension?
- left heart failure
- pulmonary embolism
- COPD
- sarcoidosis
218
Signs and symptoms of pulmonary hypertension?
- dyspnoea
- syncope
- tachycardia
- raised JVP
- hepatomegaly
- peripheral oedema
219
Investigations for pulmonary hypertension?
- ECG
- CXR (dilated pulmonary arteries and RVH)
- NT-proBNP
- echocardiogram - measure pulmonary artery pressure
220
Management of pulmonary hypertension?
- IV prostanoids
- endothelin receptor antagonists
- phosphodiesterase-5 inhibitors (sildenafil)
If secondary, manage the underlying cause.
221
Complications of pulmonary hypertension?
- right heart failure
| - respiratory failure
222
What is hypersensitivity pneumonitis?
Type III hypersensitivity reaction to an environmental allergen, resulting in parenchymal inflammation and destruction.
223
What is a type III hypersensitivity reaction?
Mediated by the formation of antigen-antibody complexes.
224
Another name for hypersensitivity pneumonitis?
Extrinsic allergic alveolitis.
225
Causes of hypersensitivity pneumonitis?
- bird-fanciers lung (bird droppings)
- farmers lung (mouldy spores in hay)
- mushroom workers lung
- malt workers lung (mould on barley)
226
Investigations for hypersensitivity pneumonitis?
Bronchoscopy and bronchoalveolar lavage - raised lymphocytes and mast cells.
227
What is bronchoalveolar lavage?
Saline solution is put through a bronchoscope to wash the airways and capture a fluid sample.
228
Management of hypersensitivity pneumonitis?
- remove allergen
| - steroids
229
Types of pneumoconiosis?
- silicosis
- coal worker's pneumoconiosis
- chronic beryllium disease
- asbestosis
230
Investigations for pneumoconiosis?
- CXR
- spirometry
- bronchoscopy biopsy / bronchoalveolar lavage
231
Management of pneumoconiosis?
- oxygen therapy
- pulmonary rehabilitation
- bronchodilator therapy
232
What is granulomatosis with polyangiitis?
Small vessel vasculitis that can present with rapidly progressive glomerulonephritis and other systemic manifestations.
Previously called Wegener's granulomatosis.
233
Antibodies in granulomatosis with polyangiitis?
cANCA
234
Signs and symptoms of granulomatosis with polyangiitis?
- dyspnoea, wheezing
- haemoptysis
- pleuritic chest pain
- nasal discharge (may be bloody)
- rhinosinusitis / otitis media
- nephritic syndrome
- fever, lethargy, weight loss, anorexia
- pupuric rash
- ophthalmic involvement
235
Investigations for granulomatosis with polyangiitis?
- biopsy of affected organs
- serum anti-cANCA antibodies
- urinalysis (haematuria and proteinuria)
- CXR (infiltrates, consolidation, effusions)
236
Management of granulomatosis with polyangiitis?
- induction therapy with corticosteroids and rituximab
| - maintenance therapy with rituximab monotherapy
237
Most common cause of upper RTI?
Rhinoviruses
238
Complications of upper RTI?
- lower RTI
- otitis media
- rhinosinusitis
239
What is a pancoast tumour?
Invades apical chest wall, compresses intercostal nerves, brachial plexus, sympathetic chain. Leads to Horner's syndrome.
240
Where do lung metastases come from?
- breast
- prostate
- bladder
- colon
