Respiratory Flashcards
What 2 conditions make up COPD?
- chronic bronchitis
- emphysema
What is COPD?
- 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
What are the classic presenting features of COPD?
- long term smoker
- SOB
- cough
- sputum production
- wheeze
- recurrent respiratory infections
How do you classify COPD?
MRC dyspnoea scale
- breathless on strenuous exercise
- breathless on walking up hill
- breathless that slows on flat
- stop to catch breath after 100m walking on flat
- unable to leave house due to breathlessness
Risk factors for COPD
- smoking
- usually between 40-60
- secondhand smoke exposure
- occupational exposure → mining, dust, cotton, wood
- pollution → heating fuel, outdoor pollutants
- alpha-1-antitrypsin deficiency
Why is A1AT implicated in COPD?
- protein made by liver
- protects lung from damage
- deficiency can lead to earlier onset and increased severity of COPD
Diagnosis of COPD
- clinical presentation
- spirometry
What can be seen in COPD spirometry?
- 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
What other tests can be done for COPD?
- chest xray → exclude others
- FBC
- BMI
- ECG
- serum A1AT
What is emphysema?
Symptoms
- dyspnoea/tachypnoea
- minimal cough
- pink skin, pursed lip breathing
- accessory muscle use
- cachexia
- hyperinflammation → barrel chest
- weight loss
complications = pneumothorax due to bullae
What is chronic bronchitis?
symptoms
- chronic productive cough → purulent sputum
- dyspnoea
- cyanosis = hypoxaemia
- peripheral oedema
- obesity
- haemoptysis
General management of COPD
- stop smoking
- pneumococcal vaccine
- annual flu vaccine
Stepwise management of COPD
- SABA or SAMA
- if no asthmatic/steroid response → LABA/LAMA, if asthmatic/steroid response → LAVA, ICS
- long term oxygen therapy
Presentation of IE COPD
- acute worsening of symptoms
- SOB, sputum, wheeze
- usually triggered by infection
Investigations for IE COPD
- ABG
- chest xray
- sputum culture and sensitivities for Ab therapy
- FBC and U&E
What does ABG show in IE COPD
- CO2 retention = acidosis
- are they in type 1 or 2 RF
normal pCO2 and low pO2 = T1RF
raised pCO2 and low pO2 = T2RF
Management of IE COPD
- steroids AND
- nebulised bronchodilators (salbutamol/upratropium bromide)
- Abs
- physiotherapy → sputum clearance
- if severe = IV aminophylline (bronchodilator), NIV (CPAP/BIPAP)
How does A1AT deficiency affect the lungs and liver?
lungs
- lack of normal A1AT
- excess protease enzymes → attack lung tissue
liver
- mutant A1AT builds up
- tissue damage → cirrhosis → HCC
Signs and symptoms of A1AT deficiency
lungs
- COPD symptoms
liver
- tiredness
- loss of appetite
- weight loss
- oedema
- jaundice
- haematemesis
Diagnosis of A1AT deficiency
- low serum A1AT
- liver biopsy
- A1AT mutant gene
- CT thorax
Management of A1AT
- no cure
- stop smoking
- symptomatic treatment
- organ transplant for end-stage liver/lung disease
- monitor for HCC
What is asthma?
- chronic inflammatory condition
- episodes of reversible airway obstruction due to:
bronchoconstriction
excessive secretion production
Causes of asthma
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
Presentation of asthma
episodes of
- wheeze → widespread, polyphonic
- breathlessness
- chest tightness
- dry cough
- family/personal history of atopy = eczema, asthma, hayfever
- diurnal variability
Investigations for asthma
spirometry with reversibility testing
- obstructive pattern
- FEV1 <80% of predicted normal
- FEV1/FVC ration <0.7
peak flow measurement
Treatment for asthma
- SABA eg salbutamol
- inhaled corticosteroid eg budesonide
- leukotriene receptor antagonist eg montelukast
- LABA eg salmeterol
- increase ICS dose
Epidemiology of TB
- majority of cases in Africa and Asia
- cause of death for most people with HIV
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
Pathophysiology of TB
spread via respiratory droplets → airborne infection
- alveolar macrophages ingest bacteria and rods proliferate inside
- drain into hilar lymph nodes → present antigen to T lymphocytes → cellular immune response
- delayed hypersensitivity reaction → tissue necrosis and granuloma formation = caseating
- primary ghon focus
- ghon complex = ghorn focus and lymph nodes
Systemic symptoms of TB
- weight loss
- low grade fever
- anorexia
- drenching night sweats
- malaise
Pulmonary symptoms of TB
- productive cough
- haemoptysis
- cough >3 weeks (dry or productive)
- breathlessness
- sometimes chest pain
Signs of TB
- signs of bronchial breathing
- dulness to percuss
- decreased breathing
- fever
- crackles
What are signs of bronchial breathing?
- loud harsh breathing sounds
- mid range pitch
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
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
Treatment for TB
RIPE
- rafampicin → 6 months
- isoniazid → 6 months
- pyrazinamide → 2 months
- ethambutamol → 2 months
MOA and side effects of rifampicin
- bactericidal → blocks protein synthesis
- red urine
- hepatitis
MOA and side effects of isoniazid
- bactericidal → blocks cell wall synthesis
- neuropathy
- hepatitis
MOA and side effects of pyrazinamide
- bactericidal initially, less effective later
- gout
- arthralgia
- rash
- hepatitis
MOA and side effects of ehtambutamol
- bacteriostatic, blocks cell wall synthesis
- optic neuritis
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
What are the types of pneumonia?
- CAP
- HAP
- atypical
- in immunocompromised patients
Pathophysiology of pneumonia
- invasion and overgrowth of a pathogen in lung parenchyma
- overwhelming of host immune defences
- production of intra-alveolar exudates
Clinical features of pneumonia
- fever
- productive cough
- increased resp and heart rate
- low BP
- dyspnoea, rigors, malaise
Signs of pneumonia
- dull to percussion
- decreased air entry
- bronchial breath sounds
Diagnosis of pneumonia
- FBC → elevated WBC
- sputum culture
- chest xray
What can be seen on a chest x-ray in pneumonia?
- multi-lobar → strep pneumoniae, s.aureus
- multiple abscesses → s.aureus
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
Treatment for pneumonia
- maintaining O2 sats between 94-98% (88-92 for COPD)
- analgesia → paracetamol/NSAIDs
- IV fluids
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
What is CAP?
- pneumonia acquired outside hospital/healthcare facilities
- commoner in extremes of age
What is HAP?
- pneumonia acquired at least 48 hours after admission to hospital and no incubating at time of admission
Causes of CAP
- strep pneumoniae
- haemophilus influenzae
- mycoplasma pneumoniae
rusty sputum = characteristic of strep pneumoniae
Causes of HAP
most cases caused by gram -ve bacilli
- pseudomonas aeruginosa
- e coli
- klebsiella pneumoniae
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
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
Risk factors of PTX
- smoking
- family history
- male
- tall and slender build
- young age
- presence of underlying lung disease
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
Clinical presentation of PTX
- stable patient
- sudden onset pleuritic chest pain, dyspnoea, cough
on examination look for
- evidence of trauma
- features of tension PTX
Diagnosis of PTX
- 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
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
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.
Clinical presentation of tension PTX
cardiopulmonary deterioration
- hypotension → imminent cardiac arrest
- respiratory distress
- low sats
- tachycardia
- shock
severe chest pain
Physical examination of tension PTX
- tracheal deviation to contralateral side
- ipsilateral reduced breath sounds
- hyperresonance on percussion
- hypoxia
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
What is cystic fibrosis?
- condition affecting mucus glands
- autosomal recessive
- defect in CFTR gene
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
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
Signs of CF
- low height/weight on growth charts
- nasal polyps
- finger clubbing
- crackles and wheezes on auscultation
- abdominal distention
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
What organisms commonly colonise in CF patients?
- s.aureus
- haemophilus influenza
- klebsiella pneumoniae
- e.coli
- psudomonas aeruginosa
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
What is whooping cough?
- URT infection
- caused by Bordetlla pertussis → gram -ve bacteria
- children/pregnant women are vaccinated against pertussis
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
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
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
What is bronchiectasis
permanent dilation of airways
Causes of bronchiectasis
- post-infection
- CF
- lung cancer
Signs and symptoms of bronchiectasis
- dyspnoea
- cough
- haemoptysis
- recurrent chest infections
Investigations for bronchiectasis
- chest xray → kerly B lines
- sputum → H.influenzae most common
Management of bronchiectasis
- physical training
- postural drainage
- prophylactic Abs
- surgery if disease localised
What is pleural effusion?
collection of fluid in the pleural cavity → space between parietal ad visceral pleura
Types of pleural effusion
exudative → high protein count
- transudative → lower protein count
Causes of exudative pleural effusion
related to inflammation
- proteins leak out of tissue into pleural space
- lung cancer
- pneumonia
- RA
- TB
Causes of transudative pleural effusion
related to fluid moving across pleural space
- congestive cardiac failure
- hypoalbuminaemia
- hypothyroidism
- Meig’s syndrome
What is Meig’s syndrome?
right sided pleural effusion with ovarian malignancy
Presentation of pleural effusion
- SOB
- cough
- stony dull percussion over effusion
- reduced breath sounds
- tracheal deviation away from effusion if large
Investigations for pleural effusion
- chest xray
- pleural US
- thoracocentesis → diagnoses underlying cause
What would you seen on a chest xray with pleural effusion
- blunting of costophrenic angle
- fluid in lung fissures
- meniscus
- tracheal and medial deviation
Treatment of pleural effusion
dependent on cause
- congestive HF → loop diuretics
- infective → Abs
- malignant → therapeutic thoracocentesis
- large effusions often need aspiration or drainage
What is interstitial lung disease?
- umbrella term for conditions that affect lung parenchyma
- cause inflammation and fibrosis
Diagnosis of interstitial lung disease
- clinical features
- high resolution CT thorax → ground glass appearance
- lung biopsy if unsure
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
What are the three types of interstitial lung disease?
- idiopathic pulmonary fibrosis
- occupational lung disorders
- systemic disease → Wegner’s, Goodpasture’s
What is idiopathic pulmonary fibrosis?
formation of scar tissue in lungs with no known cause
Presentation of IPF
- dyspnoea
- dry cough
- bibasal crackles
Treatment of IPF
- prifenidone
- nintedanib
- treatments for ILD
What is sarcoidosis?
- granulomatous inflammatory condition
- varied severity
Presentation of sarcoidosis
affects any organ in body
most common = lung
- mediastinal lymphadenopathy
- pulmonary fibrosis
- pulmonary nodules
Investigations for sarcoidosis
GOLD STANDARD = histology from biopsy
- non-caseating granulomas with epithelioid cells
Treatment for sarcoidosis
- if mild, resolves spontaneously
- oral steroids, bisphophonates
- methotrexate/azathrioprine
- lung transplant if severe
What is pulmonary HTN?
- disease of small pulmonary arteries
- vascular proliferation and remodelling
- progressive increased in PVR
What are the main vascular changes in pulmonary HTN?
- vasoconstriction
- smooth muscle cell and endothelial cell proliferation
- thrombosis
Symptoms of pulmonary HTN
- exertional dyspnoea
- lethargy, fatigue
- ankle swelling
Signs of pulmonary HTN
- accentuated component to 2nd heart sound
- tricsupid regurgitation murmur
- fatigue, peripheral oedema, cyanosis
Diagnosis of pulmonary HTN
initial tests
- chest xray → enlarged main pulmonary artery/hilar vessels
- ECG
- trans-thoracic echo
GOLD STANDARD = right heart catheterisation
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
What are the two types of bronchial carcinoma?
- small cell lung carcinoma → worse prognosis
- non-small cell carcinoma → more common
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
Risk factors of lung cancer
- smoking
- asbestos
- coal and products of coal combustion
- radon exposure
- pulmonary fibrosis
- HIV
- genetic factors
Symptoms of local disease in lung cancer
- persistent cough
- SOB
- haemoptysis
- weight loss
- chest pain
- wheeze
- infections
Symptoms of metastatic disease in lung cancer
- bone pain
- headache
- seizures
- neurological deficit
Paraneoplastic changes in lung cancer
increased
- PTH → hyperparathyroidism
- ADH → SIADH
- ACTH → Cushings
finger clubbing
Investigations for lung cancer
- 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
Treatment of lung cancer
- depends on cell type
- surgery → lobectony, segmentectomy, wedge resection
- radiotherapy
- chemo
- palliative care
Small cell lung cancer
- strong association with smoking
- arises from endocrine cells in central bronchus
- secretes polypeptide hormones
- treatment = chemo
Squamous cell carcinoma
- most strongly associated with smoking
- arises from epithelial cell in central bronchus
- associated with production of keratin
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
Secondary lung cancer
- more common than primary
can spread from
- breast
- bowel
- bladder
- prostate
- kidney
Common sites of metastasis of lung cancer
- liver
- bone
- adrenal glands
- brain
What is Goodpasture’s Syndrome?
- autoimmune anti glomerular basement membrane disease
- antibodies attack basement membrane in lungs and kidneys
- bleeding lungs, glomerulonephritis, kidney failure
Presentation of Goodpasture’s
- haemoptysis
- haematuria
- dyspnoea
- glomerulonephritis
- chest pain
- fever
- fatigue
Investigations for Goodpasture’s
lung and kidney biopsy → anti-GBM antibodies
Treatment for Goodpasture’s
- supportive
- corticosteroids
- immunosuppresants
- removal/replacement of plasma → plasmapheresis
What is hypersensitivity penumonitis?
- type 3 hypersensitivity reaction
- alveolar and bronchial inflammation after exposure to inhaled allergen
Presentation of hypersensitivity
- dyspnoea
- cough
- fever
- malaise
- weight loss
Investigations for hypersensitivity pneumonitis
bronchoalveolar lavage
- raised lymphocytes
- raised mast cells
Treatment of hypersensitivity pneumonitis
- remove allergens
- steroids
What are examples of occupational lung disorders
- silicosis
- asbestosis
- bird fanciers lung
What is pharyngitis?
rapid onset of sore throat and pharyngeal inflammation +/- exudate
Common causes of pharyngitis
- EBV
- adenoviruses
- enteroviruses
- group A streptococcus
Symptoms of pharyngitis
- sore throat
- fever
- headache, nausea, abdominal pain → kids
- rhinorrhoea, nasal congestion, cough → viral
What factors suggest a group A strep pharyngitis?
- pharyngeal exudates
- cervical adenopathy
- fever
- absence of cough/rhinorrhoea
Diagnosis of pharyngitis
- clinical symptoms consistent with group A strep infection
- rapid antigen detection test for group A strep
- -ve → conventional throat culture
Treatment of pharyngitis
- supportive → analgesia
- if group A strep, add Abs
What is sinusitis?
- inflammation of mucous membrane of nasal cavity and paranasal sinuses
- AKA acute rhinosinusitis
Causes of sinusitis
- streptococcus pneumoniae
- haemophilus influenzae
- rhinoviruses
- can progress to secondary bacterial infection
Risk factors for sinusitis
- nasal pathology → septal deviation, nasal polyps
- recent local infection → rhinitis, dental extraction
- swimming
- smoking
Viral presentation of sinusitis
- symptoms <10 days
- clear nasal discharge
- fever
- sore throat
Bacterial presentation of sinusitis
- symptoms >10 days
- purulent nasal discharge
- dental/facial pain
- headache
Investigations of sinusitis
- clinical diagnosis
- distinguish viral vs bacterial
Management of sinusitis
viral
- self limiting disease
- treatment is symptomatic
bacterial
- symptom-based therapy
- Ab generally avoided but can shorten infection
What is acute otitis media?
- inflammation of the middle ear
- associated with effusion, signs of infection
Causes of acute otitis media
viral
- RSV
- rhinovirus
- adenovirus
- influenza
most common bacterial
- H.influenzae
- S.pneumoniae
- moraxella catarrhalis
Risk factors for acute otitis media
- young
- male
- smoking
- frequent contact with other children
- family history
Presentation of acute otitis media
- otalgia
- preceding URTI symptoms
- fever
- sleep disturbance
- irritability in children
Diagnosis of acute otitis media
otoscopy → bulging and erythema of tympanic membrane
Management of acute otitis media
- regular analgesia
- amoxicillin
- consider admitting kids <3 months/ 3-6 months with temp 39+
What is acute epiglottitis
- inflammation of epiglottis
- airway emergency
- typically 2-6, can be younger
causes of acute epiglottitis
- inflammation of supraglottis
- classically with H.influenzae
- can be S.pneumoniae
Presentation of acute epiglottitis
- acute onset high fever
- toxic appearance
- tripoding
- sore throat
- dysphagia and painful
- difficulty breathing
- decreased oral intake
- stridor
Diagnosis of acute epiglottitis
- laryngoscopy during intubation in an OT
- lateral neck radiography → thumb print sign
Management of acute epiglottitis
- secure airway
- IV Abs
- supplemental O2
- maybe heliox and corticosteroids
