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Respiratory Flashcards

1
Q

What 2 conditions make up COPD?

A
  • chronic bronchitis

- emphysema

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2
Q

What is COPD?

A
  • chronic obstructive pulmonary disorder
  • non-reversible long term deterioration in air flow through the lungs
  • caused by damage to lung tissue
  • obstructive airflow through airways → SOB and prone to infection
  • not reversible with bronchodilators
  • exacerbations occur → if due to infection, these are called IE COPD
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3
Q

What are the classic presenting features of COPD?

A
  • long term smoker
  • SOB
  • cough
  • sputum production
  • wheeze
  • recurrent respiratory infections
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4
Q

How do you classify COPD?

A

MRC dyspnoea scale

  1. breathless on strenuous exercise
  2. breathless on walking up hill
  3. breathless that slows on flat
  4. stop to catch breath after 100m walking on flat
  5. unable to leave house due to breathlessness
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5
Q

Risk factors for COPD

A
  • smoking
  • usually between 40-60
  • secondhand smoke exposure
  • occupational exposure → mining, dust, cotton, wood
  • pollution → heating fuel, outdoor pollutants
  • alpha-1-antitrypsin deficiency
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6
Q

Why is A1AT implicated in COPD?

A
  • protein made by liver
  • protects lung from damage
  • deficiency can lead to earlier onset and increased severity of COPD
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7
Q

Diagnosis of COPD

A
  • clinical presentation

- spirometry

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8
Q

What can be seen in COPD spirometry?

A
  • shows obstructive picture
  • lung capacity > ability to forcefully expire air quickly
  • FEV1/FVC <0.7
  • does not respond to reversibility testing with SABA
  • severity of obstruction can be measure using FEV1
  • compare patient to predicted
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9
Q

What other tests can be done for COPD?

A
  • chest xray → exclude others
  • FBC
  • BMI
  • ECG
  • serum A1AT
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10
Q

What is emphysema?

A

Symptoms

  • dyspnoea/tachypnoea
  • minimal cough
  • pink skin, pursed lip breathing
  • accessory muscle use
  • cachexia
  • hyperinflammation → barrel chest
  • weight loss

complications = pneumothorax due to bullae

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11
Q

What is chronic bronchitis?

A

symptoms

  • chronic productive cough → purulent sputum
  • dyspnoea
  • cyanosis = hypoxaemia
  • peripheral oedema
  • obesity
  • haemoptysis
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12
Q

General management of COPD

A
  • stop smoking
  • pneumococcal vaccine
  • annual flu vaccine
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13
Q

Stepwise management of COPD

A
  1. SABA or SAMA
  2. if no asthmatic/steroid response → LABA/LAMA, if asthmatic/steroid response → LAVA, ICS
  3. long term oxygen therapy
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14
Q

Presentation of IE COPD

A
  • acute worsening of symptoms
  • SOB, sputum, wheeze
  • usually triggered by infection
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15
Q

Investigations for IE COPD

A
  • ABG
  • chest xray
  • sputum culture and sensitivities for Ab therapy
  • FBC and U&E
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16
Q

What does ABG show in IE COPD

A
  • CO2 retention = acidosis
  • are they in type 1 or 2 RF
    normal pCO2 and low pO2 = T1RF
    raised pCO2 and low pO2 = T2RF
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17
Q

Management of IE COPD

A
  • steroids AND
  • nebulised bronchodilators (salbutamol/upratropium bromide)
  • Abs
  • physiotherapy → sputum clearance
  • if severe = IV aminophylline (bronchodilator), NIV (CPAP/BIPAP)
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18
Q

How does A1AT deficiency affect the lungs and liver?

A

lungs

  • lack of normal A1AT
  • excess protease enzymes → attack lung tissue

liver

  • mutant A1AT builds up
  • tissue damage → cirrhosis → HCC
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19
Q

Signs and symptoms of A1AT deficiency

A

lungs
- COPD symptoms

liver

  • tiredness
  • loss of appetite
  • weight loss
  • oedema
  • jaundice
  • haematemesis
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20
Q

Diagnosis of A1AT deficiency

A
  • low serum A1AT
  • liver biopsy
  • A1AT mutant gene
  • CT thorax
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21
Q

Management of A1AT

A
  • no cure
  • stop smoking
  • symptomatic treatment
  • organ transplant for end-stage liver/lung disease
  • monitor for HCC
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22
Q

What is asthma?

A
  • chronic inflammatory condition
  • episodes of reversible airway obstruction due to:
    bronchoconstriction
    excessive secretion production
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23
Q

Causes of asthma

A

hypersensitivity of the airways triggered by:

  • cold air, exercise
  • cigarette smoke
  • air pollution
  • allergens → pollen, cats, dogs, horses, mould
  • time of day → early morning, night
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24
Q

Presentation of asthma

A

episodes of

  • wheeze → widespread, polyphonic
  • breathlessness
  • chest tightness
  • dry cough
  • family/personal history of atopy = eczema, asthma, hayfever
  • diurnal variability
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25
Investigations for asthma
spirometry with reversibility testing - obstructive pattern - FEV1 <80% of predicted normal - FEV1/FVC ration <0.7 peak flow measurement
26
Treatment for asthma
1. SABA eg salbutamol 2. inhaled corticosteroid eg budesonide 3. leukotriene receptor antagonist eg montelukast 4. LABA eg salmeterol 5. increase ICS dose
27
Epidemiology of TB
- majority of cases in Africa and Asia | - cause of death for most people with HIV
28
Features of TB
- aerobic, non-motile, non-sporing, slightly curved bacilli with a thick waxy capsule - acid-fast bacilli → turns red/pink with Ziehl-neelsen stain - slow growing - resistant to phagolysosomal killing and able to remain dormant
29
Pathophysiology of TB
spread via respiratory droplets → airborne infection 1. alveolar macrophages ingest bacteria and rods proliferate inside 2. drain into hilar lymph nodes → present antigen to T lymphocytes → cellular immune response 3. delayed hypersensitivity reaction → tissue necrosis and granuloma formation = caseating - primary ghon focus - ghon complex = ghorn focus and lymph nodes
30
Systemic symptoms of TB
- weight loss - low grade fever - anorexia - drenching night sweats - malaise
31
Pulmonary symptoms of TB
- productive cough - haemoptysis - cough >3 weeks (dry or productive) - breathlessness - sometimes chest pain
32
Signs of TB
- signs of bronchial breathing - dulness to percuss - decreased breathing - fever - crackles
33
What are signs of bronchial breathing?
- loud harsh breathing sounds | - mid range pitch
34
Investigations for TB
- chest xray → fibronodular opacites on upper lobes - sputum culture for acid-fast bacilli → ZN stain on Lowenstein-Jensen agar - biopsy → caseating granuloma
35
Diagnosing latent TB
Mantoux - tuberculin injected intradermally - inspect skin for signs of local skin reaction over 2-3 days Interferon gamma release assay - blood test that detects WBC response to TB antigens
36
Treatment for TB
RIPE - rafampicin → 6 months - isoniazid → 6 months - pyrazinamide → 2 months - ethambutamol → 2 months
37
MOA and side effects of rifampicin
- bactericidal → blocks protein synthesis - red urine - hepatitis
38
MOA and side effects of isoniazid
- bactericidal → blocks cell wall synthesis - neuropathy - hepatitis
39
MOA and side effects of pyrazinamide
- bactericidal initially, less effective later - gout - arthralgia - rash - hepatitis
40
MOA and side effects of ehtambutamol
- bacteriostatic, blocks cell wall synthesis | - optic neuritis
41
What is pneumonia>
- inflammation of the substance of the lungs - acute LRT infection - typically caused by bacterial infection of distal airways and alveoli - inflammatory exudate formed
42
What are the types of pneumonia?
- CAP - HAP - atypical - in immunocompromised patients
43
Pathophysiology of pneumonia
- invasion and overgrowth of a pathogen in lung parenchyma - overwhelming of host immune defences - production of intra-alveolar exudates
44
Clinical features of pneumonia
- fever - productive cough - increased resp and heart rate - low BP - dyspnoea, rigors, malaise
45
Signs of pneumonia
- dull to percussion - decreased air entry - bronchial breath sounds
46
Diagnosis of pneumonia
- FBC → elevated WBC - sputum culture - chest xray
47
What can be seen on a chest x-ray in pneumonia?
- multi-lobar → strep pneumoniae, s.aureus | - multiple abscesses → s.aureus
48
How is the severity of pneumonia assessed
CURB-65 score → 1 point each for: - confusion - urea >7 - resp rate >30 - BP <90 systolic and/or <60 diastolic - age >65 ``` 0-1 = outpatient 2 = short stay inpatient/hospital supervised outpatient 3-5 = manage as high severity pneumonia ```
49
Treatment for pneumonia
- maintaining O2 sats between 94-98% (88-92 for COPD) - analgesia → paracetamol/NSAIDs - IV fluids
50
CURB-65 guided treatment for pneumonia
``` 0-1 = oral amoxicillin at home 2 = consider hospitalising, amoxicillin (IV/oral) and macrolide 3+ = consider ITU, IV co-amoxiclav and macrolide ``` macrolide → clarithromycin/erythromycin
51
What is CAP?
- pneumonia acquired outside hospital/healthcare facilities | - commoner in extremes of age
52
What is HAP?
- pneumonia acquired at least 48 hours after admission to hospital and no incubating at time of admission
53
Causes of CAP
- strep pneumoniae - haemophilus influenzae - mycoplasma pneumoniae rusty sputum = characteristic of strep pneumoniae
54
Causes of HAP
most cases caused by gram -ve bacilli - pseudomonas aeruginosa - e coli - klebsiella pneumoniae
55
What is atypical pneumonia
bacterial pneumonia caused by atypical organisms not detectable on gram stain/cannot be culture using standard methods common organisms - mycoplasma pneumoniae - chlamydophila pneumoniae - legionella pneumophila characteristic symptoms - headache - low grade fever - cough - malaise
56
What is a pneumothorax?
air in the pleural space can be - spontaneous - traumatic → penetrating/blunt injury to chest - iatrogenic → central line/mechanical ventilation - tension - lung pathology
57
Risk factors of PTX
- smoking - family history - male - tall and slender build - young age - presence of underlying lung disease
58
Pathophysiology of PTX
- normally intrapleural pressure is -ve - when there is a bridge between alveoli and pleural space or atmosphere and pleural space - flow of air in until communication or gradient closed
59
Clinical presentation of PTX
- stable patient - sudden onset pleuritic chest pain, dyspnoea, cough on examination look for - evidence of trauma - features of tension PTX
60
Diagnosis of PTX
1. erect chest xray - reduced/absent lung markings between lung margin and chest wall - visible rim between lung margin and chest wall - bloods → clotting - US - CT → if chest xray uncertain - ABG
61
Management for PTX
small primary spontaneous PTX and not SOB - consider discharge - follow up chest xray in review large primary spontaneous PTX and/or SOB - needle aspiration - if not <2cm on repeat chest xray, insert chest drain and supplemental O2 if needed - admission secondary PTX - large = chest drain - small = needle aspiration - admission and high flow O2
62
What is a tension PTX?
- one way valve mechanism → air enters pleural space but cannot leave - increased +ve pressure in chest - collapse of ipsilateral lung - compression of contralateral, trachea, heart etc.
63
Clinical presentation of tension PTX
cardiopulmonary deterioration - hypotension → imminent cardiac arrest - respiratory distress - low sats - tachycardia - shock severe chest pain
64
Physical examination of tension PTX
- tracheal deviation to contralateral side - ipsilateral reduced breath sounds - hyperresonance on percussion - hypoxia
65
Management of tension PTX
- put out cardiac arrest call - start high flow O2 - immediate decompression - insert large bore cannula into pleural space through the second intercostal space in the mid-clavicular line - hiss sound confirms diagnosis
66
What is cystic fibrosis?
- condition affecting mucus glands - autosomal recessive - defect in CFTR gene
67
What are the key consequences of CF?
- thick pancreatic and biliary secretions that cause blockage of ducts - low volume thick airway secretions that reduce airway clearance → susceptible to airway infections - congenital bilateral absence of vas deferens in male → infertile
68
Symptoms of CF
- chronic cough - thick sputum production - recurrent respiratory tract infections - steatorrhoea - abdominal pain and bloating - parents report child's sweat tastes salty - failure to thrive
69
Signs of CF
- low height/weight on growth charts - nasal polyps - finger clubbing - crackles and wheezes on auscultation - abdominal distention
70
Diagnosis of CF
- newborn blood spot testing/heel-prick test - genetic testing for CFTR gene during pregnancy or as blood test after birth - GOLD STANDARD = sweat test → diagnostic Cl conc >60
71
What organisms commonly colonise in CF patients?
- s.aureus - haemophilus influenza - klebsiella pneumoniae - e.coli - psudomonas aeruginosa
72
Management of CF
specialist MDT - chest physiotherapy - exercise - high calorie diet - CREON tablets → digest fats - prophylactic flucloxacillin - treat chest infections - bronchodilators - lung transplant in end stage resp failure - liver transplant in liver failure - fertility treatment - genetic counselling
73
What is whooping cough?
- URT infection - caused by Bordetlla pertussis → gram -ve bacteria - children/pregnant women are vaccinated against pertussis
74
Presentation of whooping cough
- typically starts with mild coryzal symptoms → low grade fever, mild dry cough - followed by paroxysmal cough - patients produce large inspiratory whoop at tne of cough - can faint/develop PTX - infants may present with apnoeas instead of cough
75
Diagnosis of whooping cough
- nasopharyngeal/nasal swab with PCR testing/bacterial culture - if cough present for >2 weeks, can test for anti-pertussis toxin IgG
76
Management of whooping cough
- simple supportive care - vulnerable/acutely unwell/infants may need admission - macrolide Abs can be given early on - close contacts given prophylactic Abs if vulnerable key complication = bronchiectasis
77
What is bronchiectasis
permanent dilation of airways
78
Causes of bronchiectasis
- post-infection - CF - lung cancer
79
Signs and symptoms of bronchiectasis
- dyspnoea - cough - haemoptysis - recurrent chest infections
80
Investigations for bronchiectasis
- chest xray → kerly B lines | - sputum → H.influenzae most common
81
Management of bronchiectasis
- physical training - postural drainage - prophylactic Abs - surgery if disease localised
82
What is pleural effusion?
collection of fluid in the pleural cavity → space between parietal ad visceral pleura
83
Types of pleural effusion
exudative → high protein count | - transudative → lower protein count
84
Causes of exudative pleural effusion
related to inflammation - proteins leak out of tissue into pleural space - lung cancer - pneumonia - RA - TB
85
Causes of transudative pleural effusion
related to fluid moving across pleural space - congestive cardiac failure - hypoalbuminaemia - hypothyroidism - Meig's syndrome
86
What is Meig's syndrome?
right sided pleural effusion with ovarian malignancy
87
Presentation of pleural effusion
- SOB - cough - stony dull percussion over effusion - reduced breath sounds - tracheal deviation away from effusion if large
88
Investigations for pleural effusion
1. chest xray - pleural US - thoracocentesis → diagnoses underlying cause
89
What would you seen on a chest xray with pleural effusion
- blunting of costophrenic angle - fluid in lung fissures - meniscus - tracheal and medial deviation
90
Treatment of pleural effusion
dependent on cause - congestive HF → loop diuretics - infective → Abs - malignant → therapeutic thoracocentesis - large effusions often need aspiration or drainage
91
What is interstitial lung disease?
- umbrella term for conditions that affect lung parenchyma | - cause inflammation and fibrosis
92
Diagnosis of interstitial lung disease
- clinical features - high resolution CT thorax → ground glass appearance - lung biopsy if unsure
93
Treatment of interstitial lung disease
supportive, prevent progression - remove/treat underlying cause - home O2 if hypoxic at rest - stop smoking - physiotherapy - pneumococcal/flu vaccine - lung transplant
94
What are the three types of interstitial lung disease?
- idiopathic pulmonary fibrosis - occupational lung disorders - systemic disease → Wegner's, Goodpasture's
95
What is idiopathic pulmonary fibrosis?
formation of scar tissue in lungs with no known cause
96
Presentation of IPF
- dyspnoea - dry cough - bibasal crackles
97
Treatment of IPF
- prifenidone - nintedanib - treatments for ILD
98
What is sarcoidosis?
- granulomatous inflammatory condition | - varied severity
99
Presentation of sarcoidosis
affects any organ in body most common = lung - mediastinal lymphadenopathy - pulmonary fibrosis - pulmonary nodules
100
Investigations for sarcoidosis
GOLD STANDARD = histology from biopsy | - non-caseating granulomas with epithelioid cells
101
Treatment for sarcoidosis
- if mild, resolves spontaneously 1. oral steroids, bisphophonates 2. methotrexate/azathrioprine - lung transplant if severe
102
What is pulmonary HTN?
- disease of small pulmonary arteries - vascular proliferation and remodelling - progressive increased in PVR
103
What are the main vascular changes in pulmonary HTN?
- vasoconstriction - smooth muscle cell and endothelial cell proliferation - thrombosis
104
Symptoms of pulmonary HTN
- exertional dyspnoea - lethargy, fatigue - ankle swelling
105
Signs of pulmonary HTN
- accentuated component to 2nd heart sound - tricsupid regurgitation murmur - fatigue, peripheral oedema, cyanosis
106
Diagnosis of pulmonary HTN
initial tests - chest xray → enlarged main pulmonary artery/hilar vessels - ECG - trans-thoracic echo GOLD STANDARD = right heart catheterisation
107
Treatment of pulmonary HTN
supportive - treat underlying cause - oral anticoagulants - if fluid retention, diuretics - supplemental O2 - supervised exercise training - avoid pregnancy treatment-resistant patients - balloon atrial septostomy - lung transplantation
108
What are the two types of bronchial carcinoma?
- small cell lung carcinoma → worse prognosis | - non-small cell carcinoma → more common
109
Why is it useful to identify different types of lung cancer?
- different types differ in histology and behaviour - helpful for providing prognosis and determining treatment - presentations are similar
110
Risk factors of lung cancer
- smoking - asbestos - coal and products of coal combustion - radon exposure - pulmonary fibrosis - HIV - genetic factors
111
Symptoms of local disease in lung cancer
- persistent cough - SOB - haemoptysis - weight loss - chest pain - wheeze - infections
112
Symptoms of metastatic disease in lung cancer
- bone pain - headache - seizures - neurological deficit
113
Paraneoplastic changes in lung cancer
increased - PTH → hyperparathyroidism - ADH → SIADH - ACTH → Cushings finger clubbing
114
Investigations for lung cancer
1. chest xray → central mass, hilar lymphadenopathy, pleural effusion - CT chest/liver/adrenal glands → staging - sputum cytology → malignant cells in sputum GOLD STANDARD = percutaneous/bronchoscopic biopsy and histology
115
Treatment of lung cancer
- depends on cell type - surgery → lobectony, segmentectomy, wedge resection - radiotherapy - chemo - palliative care
116
Small cell lung cancer
- strong association with smoking - arises from endocrine cells in central bronchus - secretes polypeptide hormones - treatment = chemo
117
Squamous cell carcinoma
- most strongly associated with smoking - arises from epithelial cell in central bronchus - associated with production of keratin
118
Adeoncarcinoma
- most common primary lung cancer - most common type in non-smokers - originate from mucus-secreting glandular cells - metastasises to pleura, lymph nodes, brain, bone, adrenals
119
Secondary lung cancer
- more common than primary can spread from - breast - bowel - bladder - prostate - kidney
120
Common sites of metastasis of lung cancer
- liver - bone - adrenal glands - brain
121
What is Goodpasture's Syndrome?
- autoimmune anti glomerular basement membrane disease - antibodies attack basement membrane in lungs and kidneys - bleeding lungs, glomerulonephritis, kidney failure
122
Presentation of Goodpasture's
- haemoptysis - haematuria - dyspnoea - glomerulonephritis - chest pain - fever - fatigue
123
Investigations for Goodpasture's
lung and kidney biopsy → anti-GBM antibodies
124
Treatment for Goodpasture's
- supportive - corticosteroids - immunosuppresants - removal/replacement of plasma → plasmapheresis
125
What is hypersensitivity penumonitis?
- type 3 hypersensitivity reaction | - alveolar and bronchial inflammation after exposure to inhaled allergen
126
Presentation of hypersensitivity
- dyspnoea - cough - fever - malaise - weight loss
127
Investigations for hypersensitivity pneumonitis
bronchoalveolar lavage - raised lymphocytes - raised mast cells
128
Treatment of hypersensitivity pneumonitis
- remove allergens | - steroids
129
What are examples of occupational lung disorders
- silicosis - asbestosis - bird fanciers lung
130
What is pharyngitis?
rapid onset of sore throat and pharyngeal inflammation +/- exudate
131
Common causes of pharyngitis
- EBV - adenoviruses - enteroviruses - group A streptococcus
132
Symptoms of pharyngitis
- sore throat - fever - headache, nausea, abdominal pain → kids - rhinorrhoea, nasal congestion, cough → viral
133
What factors suggest a group A strep pharyngitis?
- pharyngeal exudates - cervical adenopathy - fever - absence of cough/rhinorrhoea
134
Diagnosis of pharyngitis
1. clinical symptoms consistent with group A strep infection 2. rapid antigen detection test for group A strep 3. -ve → conventional throat culture
135
Treatment of pharyngitis
- supportive → analgesia | - if group A strep, add Abs
136
What is sinusitis?
- inflammation of mucous membrane of nasal cavity and paranasal sinuses - AKA acute rhinosinusitis
137
Causes of sinusitis
- streptococcus pneumoniae - haemophilus influenzae - rhinoviruses - can progress to secondary bacterial infection
138
Risk factors for sinusitis
- nasal pathology → septal deviation, nasal polyps - recent local infection → rhinitis, dental extraction - swimming - smoking
139
Viral presentation of sinusitis
- symptoms <10 days - clear nasal discharge - fever - sore throat
140
Bacterial presentation of sinusitis
- symptoms >10 days - purulent nasal discharge - dental/facial pain - headache
141
Investigations of sinusitis
- clinical diagnosis | - distinguish viral vs bacterial
142
Management of sinusitis
viral - self limiting disease - treatment is symptomatic bacterial - symptom-based therapy - Ab generally avoided but can shorten infection
143
What is acute otitis media?
- inflammation of the middle ear | - associated with effusion, signs of infection
144
Causes of acute otitis media
viral - RSV - rhinovirus - adenovirus - influenza most common bacterial - H.influenzae - S.pneumoniae - moraxella catarrhalis
145
Risk factors for acute otitis media
- young - male - smoking - frequent contact with other children - family history
146
Presentation of acute otitis media
- otalgia - preceding URTI symptoms - fever - sleep disturbance - irritability in children
147
Diagnosis of acute otitis media
otoscopy → bulging and erythema of tympanic membrane
148
Management of acute otitis media
1. regular analgesia - amoxicillin - consider admitting kids <3 months/ 3-6 months with temp 39+
149
What is acute epiglottitis
- inflammation of epiglottis - airway emergency - typically 2-6, can be younger
150
causes of acute epiglottitis
- inflammation of supraglottis - classically with H.influenzae - can be S.pneumoniae
151
Presentation of acute epiglottitis
- acute onset high fever - toxic appearance - tripoding - sore throat - dysphagia and painful - difficulty breathing - decreased oral intake - stridor
152
Diagnosis of acute epiglottitis
- laryngoscopy during intubation in an OT | - lateral neck radiography → thumb print sign
153
Management of acute epiglottitis
1. secure airway 2. IV Abs 3. supplemental O2 - maybe heliox and corticosteroids

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