Respiratory Flashcards
1
Q
Asthma
A
paroxysmal and reversible obstruction of airways - involves bronchospasm and excessive production of secretions
2
Q
Asthma patho
A
narrowing of airway, SM contraction, airway wall thickening by cellular infiltration, inflammation, secretions
Eosinophilic - associated with allergy, subset of atopic/non-atopic
Non-eosinophilic - later onset, overlaps with smoking, obesity, neutrophils instead of eosinophils
RFs
FHx, atopy, low SES, inner city environ, obesity, premature, viral infections in early childhood, smoking
3
Q
Asthma Px
A
symptoms intermittent SOB wheeze cough (often nocturnal) sputum chest tightness
signs tachypnoea audible wheeze - widespread, polyphonic hyperinflated chest hyper-resonant percussion note reduced air entry
4
Q
Levels of acute asthma atttack
A
Moderate
increasing symptoms
PEF >50-75%
no features of severe attack
Severe cannot complete sentences HR >110 RR >25 PEF 33-50% predicted
Life-threatening silent chest confusion exhaustion cyanosis bradyacardia PEF <33% Sats <92% hypotension
Near fatal
PaCO2 increase
5
Q
Asthma DDx
A
COPD
later disease, smokers
more relentless progressive SOB with wheeze, less diurnal variation
winter symptoms, sputum production
fibrosis - would have crackles
bronchiolitis, bronchiectasis, CF, PE, bronchial obstruction, CCF, pneumothorax, PO, viral infections…
6
Q
Asthma Ix
A
Blood count - eosinophils
Atopy/allergy (SPT, RAST)
CXR
Spirometry / peak flow
Reduced FEV1, FEV1/FVC <70%
PEFR reduced, >20% variability
FeNO test
level of NO in breath - measure of inflammation
BDR test (bronchodilator reversibility) see if obstruction gets better with bronchodilator medication
Direct bronchial challenge
see if breathing worsens worsens with provocation agent (methacholine/histamine)
7
Q
Asthma Mx
A
Stop smoking, avoid precipitants, wt loss, monitor PEF
BTS guidelines
1 - SABA (salbutamol)
2 - ICS (beclometasone)
3 - LABA (salmeterol), maybe leukotriene receptor antagonist, theophylline
4 - higher dose ICS, with previous therapy
5 - oral prednisolone
omalizumab - anti-IgE Mab for persistent allergic asthma
Acute attack Assess severity - PEF, ability to speak, RR, HR, sats O2 Salbutamol Ipratropium if severe Hydrocortisone/prednisolone Reassess every 15 mins ECG Magnesium sulfate if not responding
8
Q
Bronchiectasis
A
permanent dilatation and thickening of bronchi and bronchioles after chronic inflammation
9
Q
Bronchiectasis patho
A
diffuse/local
characterised by chronic cough, excessive sputum, bacterial colonisation, recurrent acute infections
Main orgs - H.influenzae, Strep.pneumoniae, Staph.aureus, Pseudomonas aeruginosa
Results from chronic pulmonary inflammation, scarring, mucociliary transport mechanism impaired, impairment of immune function
Causes - congenital, post-infection, other (bronchial obstruction, allergic bronchopulmonary aspergillosis (ABPA), RA, UC)
10
Q
Bronchiectasis Px
A
signs
finger clubbing
coarse inspiratory crepitations
wheeze (asthma, COPD, ABPA)
symptoms persistent cough SOB copious purulent (khaki coloured) sputum intermittent haemoptysis chest pain
11
Q
Bronchiectasis DDx
A
CF, asthma, TB, pneumonia, cancer
12
Q
Bronchiectasis Ix
A
Sputum culture, bloods
CXR - cystic shadows, thickened bronchial walls, abnormal dilatation
HRCT - dilated, thickened bronchi, signet ring sign
Spirometry - obstruction
Bronchoscopy
Serum Igs, CF sweat test, SPT, RAST
13
Q
Bronchiectasis Mx
A
Healthy diet, stop smoking
Airway clearance techniques - postural drainage, chest physio
ABs
P.aeruginosa - ciprofloxacin
H.influenzae - amoxicillin, co-amoxiclav, doxycycline
S.aureus - flucloxacillin
Salbutamol
Anti-inflammatory - eg azithromycin
Surgery - if disease is localised, or to control haemoptysis
14
Q
Bronchiectasis Cx
A
pneumonia, pleural effusion, pneumothorax, haemoptysis
15
Q
COPD
A
progressive respiratory disorder characterised by airflow obstruction - airway/parenchymal damage
obstruction = FEV1/FVC <0.7
Resp drive normally PaCO2 driven, but in COPD, hypoxia can be a strong drive, so resp drive can be reduced if hypoxia is corrected
16
Q
COPD patho
A
Small airways disease - chronic bronchitis
airway inflammation, fibrosis, luminal plugs, increased airway resistance, cough, sputum production
Parenchymal destruction - emphysema
loss of alveolar attachments, decrease of elastic recoil, alveolar wall destruction
Vascular changes
V/Q mismatch, low PaO2, high PaCO2, pul HTN may result
A1AT deficiency
A1AT is a protease inhibitor, normally protects tissues from enzymes from inflammatory cells (neutrophil elastase -> loss of recoil)
Causes
smoking, air pollution, occupational exposure
RFs
male, older, asthma, A1AT deficiency, low SES, HIV
17
Q
COPD Px
A
signs tachypnoea use of accessory muscles of resp (might lean forward) hyperinflation (barrel shaped chest) decreased expansion resonant/hyper-resonant percussion note expiration through pursed lips quiet breath sounds cyanosis cor pulmonale, peripheral oedema, raised JVP cachexia
symptoms SOB cough sputum wheeze minimal diurnal variation wt loss
PP vs BB
PP - increased alveolar ventilation, normal PaO2, breathless, not cyanosed
BB - decreased alveolar ventilation, low PaO2, high PaCO2, cyanosed, not breathless, resp centres insensitive to CO2, rely on hypoxic drive
18
Q
COPD DDx
A
Asthma, HF, other causes of SOB, PE, pneumonia, lung cancer, bronchiectasis, TB
COPD / asthma? age usually younger in asthma smoking history - in most with COPD SOB variable in asthma nocturnal symptoms more common in asthma persistent productive cough common in COPD, not asthma
19
Q
COPD Ix
A
Spirometry - FEV1/FVC < 0.7, FEV1 < 80%
CXR - hyperinflation, flat hemidiaphragms, large central pulmonary arteries, bullae
CT - bronchial wall thickening, scarring, air space enlargement
ECG - cor pulmonale
ABG - decreased PaO2 +/- hypercapnia
FBC - identify anaemia / polycythaemia
MRC SOB scale, NICE COPD severity classification
20
Q
COPD Mx
A
Stop smoking, influenza and pneumonia vaccines, pulmonary rehab
Bronchodilators SABA - salbutamol LABA - salmeterol, formoterol SAMA - ipratropium LAMA - tiotropium Theophylline - bronchodilator, suppresses airway response to stimuli
ICS - beclometasone, fluticasone
Combination therapy of above
Oxygen therapy
NIV (non-invasive ventilation)
Phosphodiesterase t4 inhibitors - anti-inflammatory - eg roflumilast
Mucolytics
Surgery - bullectomy, lung volume reduction surgery, transplant
OVERALL
- SABA / SAMA
- If steroid responsive / asthmatic = add LABA + ICS
- If not steroids responsive / non-asthmatic = add LABA + LAMA
- Oral theophylline
- Long term oxygen therapy
Do not prescribe LAMA and SAMA together, if started on LAMA, remove SAMA
21
Q
COPD Cx
A
Acute exacerbation, infection secondary polycythaemia (not enough O2 reaching tissues, EPO increases) resp failure pneumothorax lung carcinoma reduced QoL
22
Q
COPD acute exacerbation
A
acute worsening of symptoms
commonly viral cause, also bacterial, air pollutants
Tx - nebulised bronchodilators, O2, steroids, ABs, aminophylline/theophylline, doxapram (respiratory stimulant drug), NIV
23
Q
CF
A
autosomal recessive multi-organ disease, resp problems, pancreatic insufficiency, characterised by thickened secretions
24
Q
CF patho
A
mutations in CFTR gene (chromosome 7) - chloride channel exporting Na and Cl
defective -> not enough Cl secretion, increased Na absorption, less water secreted -> thickened secretions
(in sweat gland, cannot reabsorb Cl, thus Na also not reabsorbed)
- High sodium sweat
- Pancreatic insufficiency - dehydration of secretions, they stagnante in ducts
- Biliary disease - concentrated bile, plugging, local damage
- GI disease - highly viscous secretions, intraluminal water deficiency
- Resp disease - dehydration of airway surfaces, reduced mucociliary clearance, favours bacteria, inflammatory lung damage
RFs - FHx
25
CF Px
Neonates
failure to thrive, meconium ileus, rectal prolapse
```
Respiratory
cough
thick mucus
wheeze
recurrent infections
bronchiectasis, airflow limitation
sinusitis
nasal polyps
spontaneous pneumothorax
haemoptysis, SOB
```
```
Alimentary
thick secretions
reduced pancreatic enzymes
pancreatic insufficiency - DM, steatorrhoea
distal intestinal obstruction syndrome
reduced bicarb
malabsorption
cholesterol gallstones, liver cirrhosis
peptic ulcers, malignancy
```
```
Others
male infertility
females can conceive, often develop secondary amenorrhea as disease progresses
salty sweat
clubbing
osteoporosis
bilateral coarse crackles
cyanosis
FEV1 - obstruction
```
26
CF Ix
Sweat test - high sodium and chloride
Genetic testing
CXR, thorax CT
Lung function tests, spirometry
Sputum micro, swab (common orgs - H.influenzae, S.aureus, P.aeruginosa, E.coli, K.pneumoniae)
Bloods
27
CF Mx
Stop smoking, good nutrition
```
Chest
Postural drainage, chest physio
ABs, for infection and prophylaxis
Mucolytics - dornase alfa
Bronchodilators
```
GI
pancreatic enzyme replacement
ADEK vitamin supplements
Ursodeoxycholic acid for impaired liver function
Tx CF-related diabetes
Advanced lung disease - O2, diuretics, ventilation, transplant
28
CF Cx
Resp disease - infection, bronchiectasis, cor pulmonale, death`
29
Extrinsic allergic alveolitis
diffuse granulomatous inflammation of lung parenchyma - response to organic antigens
aka hypersensitivity pneumonitis
30
EEA patho
allergic reaction to inhaled antigen (eg fungal spores, avian proteins)
acute and subacute - pneumonitis
chronic - fibrosis, emphysema, permanent damage
T3 HYPERSENSITIVITY - inflammation through activation of complement via classical pathway
Associations:
Farmer's lung, pigeon fanciers lung, cheese-workers lung, malt-workers lung, humidifier fever, hot tubs
31
EAA Px
```
Acute
fever
rigors
myalgia
dry cough
SOB
crackles (no wheeze)
chest-tightness
```
subacute
less severe as acute, gradual onset, can present as recurrent pneumonia
chronic
cyanosis, clubbing, wt loss, increasing SOB, T1 resp failure, cor pulmonale
32
EEA DDx
infection, connective tissue disorder, pulmonary fibrosis, asthma, drug-induced ILD
33
EEA Ix
Take good history
CXR - fibrotic shadow in upper zone (upper zone mottling)
HRCT
FBC - WCC, ESR increased
PFTs - reversible restrictive defect, reduced gas transder
Bronchoalveolar lavage - analysis of lymphocyte count
34
EEA Mx
Acute
remove antigen
O2
oral prednisolone
Chronic
avoid allergen exposure
long term prednisolone
35
EEA Cx
Spontaneous pneumothorax, pulmonary fibrosis, emphysema, resp failure
36
Goodpasture's syndrome
autoimmune disease - acute glomerulonephritis and pulmonary alveolar haemorrhage
37
GP syndrome patho
circulating anti-GBM ABs - ABs against an intrinsic antigen to BMs of kidney and lung
RFs - genetics, exposure to organic solvents, hydrocarbons, smoking, infection
38
GP syndrome Px
upper RTI symptoms - sneezing, nasal discharge, nasal congestion, runny nose, fever
signs
anaemia (from persistent intrapulmonary bleeding)
acute glomerulonephritis
tachypnoea, SOB, inspiratory crackles, cyanosis, HTN
massive pulmonary haemorrhage -> resp failure
```
symptoms
cough
intermittent haemoptysis
tiredness
chills, fever, N+V, wt loss, chest pain
```
39
GP syndrome DDx
idiopathic pulmonary haemosiderosis, SLE, RA
40
GP syndrome Ix
anti-GBM ABs in blood
CXR - transient patchy shadows - due to haemorrhage, often in lower zones
Kidney biopsy
41
GP syndrome Mx
Some patients spontaneously improve
Tx shock
Immunosuppression - methylprednisolone, cyclophosphamide, azathioprine, then oral prednisolone
Plasmapheresis - remove blood, clean to remove ABs, insert back
42
GP syndrome Cx
resp failure, AKI, CKD
43
Granulomatosis with polyangiitis (GPA)
multisystem disorder characterised by necrotising granulomatous inflammation and vasculitis of small/medium vessels
44
GPA patho
ANCA-associated - anti-neutrophil cytoplasmic AB
neutrophils activated inappropriately, ROS production, neutrophil degradation, inflammation and granuloma formation
most commonly presents with lesions in upper resp tract, lungs, kidneys
sinuses, eyes, skin may also be affected
45
GPA Px
rhinorrhoea (nasal congestion), then nasal mucosal ulceration - 'saddlenose' deformity
signs
renal disease - glomerulonephritis with crescent formation, proteinuria, haematuria
skin purpura, peripheral neuropathy, arthritis/arthralgia
```
symptoms
cough
pleuritic pain
haemoptysis
fever
```
46
GPA DDx
Churg-Strauss syndrome, GP syndrome, SLE, RA with systemic vasculitis
47
GPA Ix
Bloods - c-ANCA positive, also p-ANCA, raised ESR, CRP
CXR - nodular masses of pneumonic infiltrates with cavitation
CT - maybe diffuse alveolar haemorrhage
Biopsy of affected tissue
Urinalysis - proteinuria/haematuria, if yes consider renal biopsy
48
GPA Mx
Prednisolone, cyclophosphamide, rituximab
azathioprine, methotrexate
plasma exchange
surgery - nasal deformity, AKI (renal transplant)
49
GPA Cx
AKI, resp failure, chronic conjunctivitis, nasal septum perforation
50
Influenza
acute resp illness due to infection with influenza virus
51
Influenza patho
Droplet infection and contact
Three serotypes
- A - more frequent, major outbreaks
- B - less severe
- C - mild, like common cold
Antigens
H - haemagglutinin (15) - facilitates virus entry into host cell
N - neuraminidase (9) - facilitates virion release from infected cell
Antigenic drift - mutations to surface antigens
52
Influenza Px
```
1-4 day incubation
fever
dry cough
sore throat
coryzal symptoms - catarrhal inflammation of nose
headache
malaise
myalgia
anorexia
conjunctivitis
eye pain +/- photophobia
```
```
complications
pneumonia
chronic lung disease exacerbation
croup
otitis media
D+V
myositis
encephalitis
Reye syndrome - encephalopathy + fatty degenerative liver failure
```
53
Influenza DDx
common cold, URTI, pharyngitis, LRTI, malaria/dengue fever, CMV, infecious mononucleosis
54
Influenza Ix
Clinical Dx
for community surveillance - viral culture of nasopharyngeal swabs, PCR
55
Influenza Mx
Paracetamol, fluids
Antivirals (oseltamivir, zanamivir) if high risk - chronic disease, immunosuppression, pregnant, >65yo, <6 months, BMI >40
Vaccine
56
Lung cancer
95% of primary lung tumours are bronchial carcinomas
metastases are more common than primary tumours, typical primary sites - kidney, prostate, bone, GI, cervix, ovary
57
Lung cancer patho
SCLC
15%, associated with smoking, arises from endocrine cells, highly malignant, poor prognosis
NSCLC
85%
- squamous - smoking, from epithelial cells
- adenocarcinoma - most common type in non-smokers (asbestos), from mucous cells in bronchial epithelium, often metastasises
- large cell
- carcinoid tumour
- bronchoalveolar cell
Benign tumours
Bronchial adenoma
Hamartoma
Tumours can spread within chest, may directly involve pleura and ribs - pain and bone fractures
RFs
smoking, occupational exposure, pre-existing lung disease, radiation
58
Lung cancer Px
```
symptoms of local disease
cough
SOB
haemoptysis
chest pain
wheeze
recurrent infections
clubbing
lethargy, wt loss, anorexia
```
```
symptoms of metastatic disease
bone pain
headache
seizures
neurological deficit
hepatic pain
abdo pain
```
```
paraneoplastic changes - side effect of tumour
PTH secretion
SIADH
ACTH secretion
DIC
non-infective endocarditis
```
Pancoast tumour - at pulmonary apex, compresses brachial plexus - Horner's syndrome
59
Lung cancer Ix
TNM classification
```
CXR
round shadow
edge has fluffy spiked appearance
hilar enlargement
consolidation
lung collapse
pleural effusion
```
CT, PET-CT
Bronchoscopy +/- endobronchial USS
Biopsy - lung and lymph nodes
Bloods, cytology, PFTs
60
Lung cancer Mx
NSCLC
Lobectomy
Radiotherapy, chemo, cetixumab
SCLC
Chemo, radio
relieve symptoms - eg dexamethasone for SVC obstruction
Endobronchial therapy - for airway narrowing - stenting, cryotherapy
Pleural drainage
Drugs - analgesia, steroids, antiemetics, codeine, bronchodilators, antidepressants
61
Mesothelioma
tumour of mesothelial cells
80-90% in pleura, other sites are peritoneum, pericardium, testes
associated with asbestos exposure
62
Mesothelioma patho
high grade malignancy, begins as nodules, chest wall often invaded (infiltration of intercostal nerves), lymphatics (hilar node metastases)
63
Mesothelioma Px
signs
finger clubbing
recurrent pleural effusions
signs of metastases - lymphadenopathy, hepatomegaly, bone pain/tenderness, abdo pain/obstruction
symptoms
chest pain
SOB
wt loss
64
Mesothelioma Ix
CXR, CT - unilateral pleural effusion, pleural thickening
Bloody pleural fluid
Biopsy
65
Mesothelioma Mx
Generally resistant to surgery, chemo, radio
Poor prognosis
Surgery for extremely localised disease
66
Occupational lung disorders
response to inhaling something at work
67
Occupational asthma
asthma symptoms worse at work
Ix - peak flow diary - compare variations between work and home
68
Pneumoconiosis
accumulation of dust in lungs and tissue reaction to it
eg coal-workers pneumoconiosis
particles ingested by alveolar macrophages in small airways and alveoli, which die, release enzymes - can lead to massive fibrosis
69
Silicosis
inhalation of silica particles - very fibrogenic
particularly toxic to alveolar macrophages
CXR - diffuse nodular pattern, egg-shell calcification of hilar nodes
restriction on spirometry
70
Asbestos
time lag between exposure and development of disease - risk of primary lung cancer, mesothelioma
71
Asbestosis`
ILD - cellular infiltrates and extracellular matrix deposition
fibrosis of lungs
SOB, finger clubbing, bilateral end-inspiratory crackles
Ferruginous asbestos bodies on microscopic examination, causes pleural plaques
Mx - corticosteroids
72
Pleural plaques
layers of collagen, often calcified
73
Diffuse pleural thickening
lung expansion restricted by thickened pleura
74
Byssinosis
inhalation of textile fibre dust
symptoms worse at work - chest tightness, cough, SOB, asthmatics badly affected
75
Pulmonary siderosis
inhalation of metallic particles
Iron shadows on CXR
Little effect on lung function
76
Pleural effusion
excessive accumulation of fluid in the pleural space
77
Pleural effusion patho
Transudate (<25g/l)
transparent fluid, less protein, vessels normal, only fluid can leak out, when hydrostatic forces favour fluid accumulation
- increased venous pressure - HF, constrictive pericarditis, fluid overload
- hypoproteinaemia - cirrhosis, nephrotic syndrome
- peritoneal dialysis
- hypothyroidism
Exudate (>35g/l)
exudes protein, capillaries are leaky
- secondary to infection, inflammation, malignancy
```
Rarely, effusions consist of:
Blood - haemothorax
Pus - empyema
Lymph - chylothorax
Blood and air - haemopneumothorax
```
78
Pleural effusion Px
can be asymptomatic
```
signs
decreased chest expansion - on side of effusion
tracheal deviation
stony dull percussion
diminished breath sounds
loss of vocal resonance
maybe bronchial breathing
```
```
symptoms
SOB, especially on exertion
pleuritic chest pain
cough
wt loss - malignancy
```
79
Pleural effusion Ix
```
CXR
blunting of costophrenic angles
fluid in horizontal/oblique fissure
meniscus
mediastinal shift away from effusion
```
Diagnostic aspiration - thoracentesis / pleural tap
aspirate fluid - purulent (pus), turbid/cloudy (infection), milky (lymph)
send to cytology, microbio
Maybe parietal pleural biopsy, USS
80
Pleural effusion Mx
Tx cause
Drain effusion
Pleurodesis with talc - causes pleura to adhere
Chest drain to tx empyemas - also intra-pleural alteplase and dornase alfa may help
Surgery - for persistent collections
81
Pneumonia
inflammation of lungs, infiltration of neutrophils, formation of inflammatory exudate
spread by resp droplets
82
Community acquired pneumonia
outside hospital/clinic
affects extremes of age
Strep pneumoniae most commonly, then H.influenzae
Mycoplasma pneumoniae, legionella, S.aureus, E.coli, klebsiella - rarely
Infection can be localised (lobar) or diffuse
83
Hospital acquired pneumonia
pneumonia after >48hrs admission, or been in healthcare for last 3 months
elderly, ventilator associated, post-operative
Aerobic G- bacilli mostly - P.aeruginosa, E.coli, Klebsiella pneumoniae
S.aureus, MRSA
84
Immunocompromised pneumonia
risk from usual orgs and opportunistic infections
85
Aspiration pneumonia
acute inspiration of gastric contents into lungs
eg stroke, myasthenia, bulbar palsies, lack of consciousness, oesophageal disease
86
Pneumonia Px
```
signs
raised RR, SOB
coarse crackles
dull to percussion
bronchial breath sounds
dry/productive cough
purulent sputum
raised HR
low BP
cyanosis
confusion
```
```
symptoms
fever
night sweats
rigors
malaise
anorexia
haemoptysis
pleuritic chest pain
```
87
Pneumonia DDx
TB, lung cancer, PO, pleural effusion, pneumothorax, asthma, COPD
88
Pneumonia Ix
CXR
lobar/multilobar infiltrates, cavitation, pleural effusion
consolidation
multi-lobar - S.pneumoniae, S.aureus, legionella
Multiple abscesses - S.aureus
Upper lobe cavity - klebsiella pneumoniae
Bloods - FBC - WCC, ESR, CRP elevated
Biochem - U+E, LFT, renal, HIV test
Sputum culture, blood culture and serology
Urine - urinary antigens
CURB-65 to assess severity - confusion, urea >7mmol/L, RR>30, BP<90, age >65
89
Pneumonia Mx
O2 - sats 94-98% (88-92% in COPD)
IV fluids
ABs
Analgesia - NSAIDs, paracetamol
Mild - amoxicillin
Severe - co-amoxiclav / clarithromycin
Pneumococcal vaccine
90
Pneumonia Cx
resp failure, hypotension, sepsis, pleural effusion, empyema, lung abscess, brain abscess, pericarditis, myocarditis
91
Pneumothorax (PTX)
air in pleural cavity, can lead to partial/total lung collapse
92
PTX patho
simple - 2-way valve, trachea usually central
- closed - atm pressure > pleural space
- open - pressures are equal
tension - 1-way valve, on every breath, more air dragged into pleural space, tracheal deviation away from side affected
- pressure greater in pleural cavity
lung loses elastic recoil, pressure in pleural space no longer negative
```
Causes
spontaneous - young thin men, bullae
chronic lung disease - COPD, asthma, CF, fibrosis, sarcoidosis
Infection
Trauma
Carcinoma
Connective tissue disorders - Marfan's
```
93
PTX Px
Can be asymptomatic - young, fit, small PTX
mechanically ventilated - sudden hypoxia, increase in ventilation pressures
```
signs
reduced chest expansion
hyper-resonant percussion
diminished breath sounds
tracheal deviation
pulsus paradoxus (pulse slows on inspiration)
distended neck veins
```
symptoms
sudden onset SOB
pleuritic chest pain, sudden onset
94
PTX DDx
chest pain, pleural effusion, PE
95
PTX Ix
CXR
if tension suspected, tx first then scan
small PTX - air tends to collect at apices
USS, CT, ABG - hypoxia
96
PTX Mx
Needle thoracostomy - large bore needle with syringe (partially saline filled) or large bore cannula - 2nd intercostal space, mid-clavicular
Chest drain - in triangle of safety
Surgery - if needed
97
PE
obstruction within pulmonary artery tree by embolus
98
PE patho
venous thrombus, usually from DVT
blocks RV outflow - increase in pulmonary vascular resistance, RHF
small embolus may be clinically silent until it causes pulmonary infarction
V/Q mismatch - ventilated but not perfused
Causes
Thrombosis - DVT
fat - long bone fracture or orthopaedic surgery
Amniotic fluid
Air - eg neck vein cannulation, bronchial trauma
RFs
malignancy, surgery, immobility, pregnancy, HRT, cOCP
99
PE Px
```
signs
tachypnoea, tachycardia
hypoxia -> anxiety, restlessness, agitation, impaired consciousness
pyrexia
elevated JVP
gallop heart rhythm - split S2, tricuspid regurg murmur
pleural rub
systemic hypotension, cardiogenic shock
```
```
symptoms
SOB
pleuritic chest pain, retrosternal chest pain
cough, haemoptysis
DVT symptoms
RHF -> dizziness, syncope
```
100
PE Ix
CT pulmonary angiography
Assess risk of PE - Wells score
Bloods, troponin, BNP, D-dimer, clotting screen, ABG
ECG - tachycardia, RV strain pattern V1-3, right axis deviation, RBBB, AF, deep S waves in I, Q waves in III, inverted T waves in III (SI, QIII, TIII)
CXR
V/Q scan
101
PE Mx
Oxygen
Morphine, antiemetic
LMWH / fondaparinux
Fluids if low BP
consider thrombolysis if haemodynamically unstable - alteplase
long-term anticoagulation - DOAC (rivaroxaban) or warfarin
Surgical embolectomy maybe
102
Pulmonary fibrosis
interstitial lung damage, fibrosis, loss of elasticity of lungs
103
PF patho
3 types:
- replacement fibrosis secondary to lung damage, eg infarction, TB, pneumonia
- focal fibrosis in response to irritants, eg coal dust, silica
- diffuse parenchymal lung disease (DPLD) - in idiopathic pulmonary fibrosis (IPF), and EEA
associated with connective tissue disorders, eg RA, SLE, systemic sclerosis, Sjogrens
```
Causes/RFs
IPF cause unknown
Occupational exposure
Irritants
Drugs
Smoking
Chronic viral infections
```
104
PF Px
signs
cyanosis
finger clubbing
fine end-inspiratory crepitations
```
symptoms
dry cough
SOBOE
malaise
decreased weight
arthralgia
```
105
PF DDx
HF, COPD, sarcoidosis, PE, lung cancer, EEA, pneumonia, asbestosis
106
PF Ix
Bloods - ABG, CRP increased, Igs, ANA, RF
CXR - reduced lung volume, bilateral lower zone reticulo-nodular shadows, honey-comb lung
HRCT
Spirometry - restrictive
Decreased gas transfer
Bronchoalveolar lavage, biopsy
107
PF Mx
O2, pulmonary rehab, exercise, weight control
Pirfenidone - anti-inflammatory, anti-fibrotic immunosuppressant
Nintedanib - tyrosine kinase inhibitor with antifibrotic and anti-inflammatory properties
Lung transplant, corticosteroids
108
Pulmonary HTN
increase in mPAP (mean pulmonary arterial pressure) above 25mmHg
109
Pulmonary HTN patho
hypoxic vasoconstriction, inflammation, cell proliferation, narrower vessels, endothelium damage, vasoconstrictor release, serotonin - increase in resistance
```
Causes
PE, veno-occlusive disease
COPD, chronic lung diseases
CV - mitral stenosis, LV HF, congenital
Resp drive disturbances - obstructive sleep apnoea, obesity
MSK - kyphoscoliosis, poliomyelitis, MG
SSc, SLE, RA, Sjogrens, drugs, genetic
```
110
Pulmonary HTN Px
```
signs
right parasternal heave, due to RVH
loud pulmonary S2
elevated JVP
as RHF - ascites, oedema, abdo pain (hepatic congestion)
```
```
symptoms
SOBOE
fatigue, lethargy
ankle swelling
chest pain
syncope
cor pulmonale
```
111
Pulmonary HTN DDx
cor pulmonale, cardiomyopathies, RHF, CCF, portal HTN
112
Pulmonary HTN Ix
```
CXR
enlarged vessels
lucent lung fields
enlarged RA, RV
may show cause - eg emphysema, calcified mitral valve
```
ECG - RVH, p pulmonale (tall, peaked P wave)
ECHO - RVH
PFTs, MRI, LFTs, TFTs, autoimmune screening - ANAs
Right heart catheterisation to confirm dx
113
Pulmonary HTN Mx
Tx cause
Oxygen
Warfarin - intrapulmonary thrombosis
Diuretics for oedema
CCB, eg amlodipine - pulmonary vasodilators
Prostacyclin analogue - iloprost
Endothelial receptor antagonists - bosentan
Phosphodiesterase-5 inhibitor - sildenafil - modulate effects of nitric acid on vascular tone
Consider heart-lung transplant in young
114
Pulmonary HTN Cx
RHF, peripheral oedema, pleural effusions, hepatic congestion, sudden cardiac death
115
Sarcoidosis
multisystem granulomatous disorder of unknown cause
characterised by formation of non-caseating epithelioid granulomata at various sites in body
has predilection for lungs and thoracic cavity - type of ILD
116
Sarcoidosis patho
granulomas - epithelioid cells, macrophages, lymphocytes
cause generally unknown
in lung - cellular infiltrates, ECM deposition, granuloma formation
RFs
FHx, race - Afro-Caribbeans, genetics
117
Sarcoidosis Px
asymptomatic
```
acute sarcoidosis
fever
erythema nodosum - red lumps on shins, thighs + forearms less commonly
polyarthralgia
bilateral hilar lymphadenopathy (BHL)
```
```
pulmonary disease
abnormal CXR, BHL, pulmonary infiltrates, fibrosis
dry cough
progressive SOB
decreased exercise tolerance
chest pain
```
```
other symptoms
lymphadenopathy
HSM
deranged LFTs
conjunctivitis
glaucoma
anterior uveitis
hypercalciuria, renal stones
enlargement of lacrimal, parotid glands
Bell's palsy
facial numbness, dysphagia, visual field defects
lupus pernio - blue/red/purple nodules/plaques over nose, cheek, ears
cardiac arrhythmias, heart block
```
118
Sarcoidosis DDx
RA, lymphoma, metastatic malignancy, TB, lung cancer, SLE, IPF, myeloma
(see notes for DDx of granulomatous diseases)
119
Sarcoidosis Ix
CXR - BHL, grade infiltration 0-4
Bloods - raised ESR, Ca, Igs, serum ACE, lymphopenia, LFTs
24hr urinary calcium
Bronchoscopy, ECG, PFTs
Tissue biopsy - shows non-caseating granulomata
Bronchoalveolar lavage, Xray, CT/MRI
120
Sarcoidosis Mx
Acute
bed rest, NSAIDs
If indicated, prednisolone, then gradually decrease dose
```
Severe
IV methylprednisolone
Immunosuppressants (methotrexate, hydroxychloroquine, ciclosporin, cyclophosphamide)
Anti-TNF alpha maybe
Lung transplant
```
121
TB
chronic granulomatous disease caused by Mycobacterium spp
aerobic slightly curved acid fast bacilli, go red/pink with ZN stain
spread by droplet infection
122
TB patho
Primary TB
first infection, bacteria proliferate inside macrophages, delayed T4 hypersensitivity - tissue necrosis, granuloma formation (ghon focus), fibrosis, bacilli can be taken to lymph nodes (secondary lesions), caveated areas heal, may calcify, some contain bacteria - lie dormant for years
Latent TB
In majority infected by TB, immune system contains infection, patient develops cell-mediated immunity
```
Reactivation TB (secondary)
reactivation of latent infection, usually where there is depression of host immune system - older, severe infection
```
Miliary TB
infection not adequately contained, invades bloodstream, severe disease
Transmission of TB
cavities erode into airways, bacilli can escape, infect more people when patient coughs
RFs
close contact with TB patient, originate from high-incidence countries, homeless, alcohol dependent, immunocompromised, elderly, children, debilitating disease, poverty, malnutrition
123
TB Px
```
systemic
wt loss
low grade fever
anorexia
night sweats
malaise
clubbing (bronchiectasis)
erythema nodosum
```
```
pulmonary TB
asymptomatic
productive cough, occasional haemoptysis
cough >3wks
pleuritic pain
chest pain
breathlessness
hoarse voice if laryngeal involvement
associated with - consolidation, pleural effusion, pulmonary collapse
```
```
extrapulmonary TB (rare in primary TB)
lymph node - swelling, discharge
bone - pain, joint swelling
abdo - ascites, malabsorption
GU - epididymitis, frequency, dysuria, haematuria, pyuria
CNS - meningitis, cranial palsies, raised ICP
cardiac - pericarditis, effusion, constrictive
skin - lupus vulgaris - red/brown skin lesions
```
124
TB DDx
carcinoma, lymphoma, pneumonia, fibrotic lung disease, chronic diseases, eg diabetes, anorexia nervosa
125
TB Ix
CXR - patchy/nodular shadows in upper zone, loss of volume, fibrosis +/- cavitation
consolidation, miliary shadows on miliary TB
Sputum - ZN stain, bronchoscopy if no sputum available
Histology - caseating granulomata
Culture - liquid/broth culture
Nucleic acid amplification test (NAAT)
LP, CSF examination
Latent TB Dx
Tuberculin skin test - mantroux
Interferon gamma release assays (IGRAs)
126
TB Mx
RIPE - 6 month tx for fully sensitive TB, CNS TB = 12 months, bone = 9
Rifampicin - 6 months - s/e red urine, hepatitis
Isoniazid - 6 months - s/e hepatitis, neuropathy (pyridoxine, vit B6, given daily to prevent)
Pyrazinamide - 2 months - s/e hepatitis, arthralgia/gout, rash
Ethambutol - 2 months - s/e optic neuritis
Prevention - contact tracing, vaccination - neonatal BCG, for certain higher risk groups, but not offered routinely
127
Pharyngitis / tonsillitis
infections in throat, inflammation
Common viruses - adenoviruses, rhinovirus, EBV, acute HIV
Bacterial - lancefield group A beta-haemolytic streptococci, eg strep pyogenes
```
Px
sore throat
fever
red oropharynx, soft palate
large tonsils, soft palate
tender anterior cervical lymph nodes
```
Mx
self-limiting
persistent/severe tonsillitis - phenoxymethylpenicillin / cefaclor
128
Sinusitis
infection of paranasal sinus
viral - most common
Bacterial - strep pneumoniae, H.influenzae
```
Px
fever
facial pain
purulent nasal discharge
pain in ears and teeth, often unilateral
cold-like symptoms
```
Mx
nasal decongestants - xylometazoline
broad spec ABs - co-amoxiclav
Cx
brain abscess, sinus vein thrombosis
129
Acute epiglottitis
inflammation of epiglottis
most severe due to H.influenzae
rarer due to HiB (H influenzae type B) vaccine
Px
fever
airflow obstruction
sore throat, pain on swallowing (odynophagia)
inspiratory stridor
fatigue, wt loss, diarrhoea with oral thrush
Ix
laryngoscopy
lateral neck x ray
Mx
can be life threatening - endotracheal intubation
IV AB - ceftazidime
130
Whooping cough
Bordetella pertussis (G- coccobacillus)
disease of children <5yo
```
Px
chronic cough
febrile
subconjunctival haemorrhage
lungs clear to auscultation
incubation 7-10 days
CATARRHAL PHASE 1-2wks
patient highly infectious
malaise
anorexia
rhinorrhoea
conjunctivitis
PAROXYSMAL PHASE 1-6 wks
coughing spasm, usually terminate in vomiting
classic inspiratory whoops
```
```
Ix
PCR test
oral fluid test for IgG
serology - for anti-pertussis toxin IgG
nasopharyngeal swab
```
Mx
macrolides, eg clarithromycin - catarrhal stage (ABs have little effect in paroxysmal stage)
Vaccination (6-in-1)
Cx
pneumonia
encephalopathy
131
Croup / acute laryngotracheobronchitis
acute laryngitis, occasionally a cx of URTI
mainly due to parainfluenza
inflammatory oedema extends to vocal cords and epiglottis - narrowing of neck and abdomen during inspiration - severe cases, central cyanosis
```
Px
barking cough, crying
febrile
RR increased
cyanosed, prominent intercostal recessions
inspiratory stridor
```
Mx
nebulised adrenaline
Corticosteroids, eg dexamethasone
O2, fluids
