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Respiratory Flashcards

1
Q

Pathophysiology of Asbestos-related Lung Disease

A

Asbestos activates macrophages and neutrophils which causes the release of reactive oxygen species and nitrogen species which causes DNA damage, thus increasing the risk of cancer

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2
Q

What 2 pleural features are seen in asbestos-related lung disease?

A

Pleural plaques- which are BENIGN and usually detected on CXR incidentally and this is the most common form of asbestos-related lung disease

Pleural thickening- there is diffuse pleural thickening, similar to haemothorax or empyema

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3
Q

Is asbestosis restrictive or obstructive? and are the lower or upper zones predominantly affected?

A

restrictive disease and the lower zones are predominantly affected in asbestosis

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4
Q

What is mesothelioma?

A

it is a form of asbestos-related lung disease. it is a malignant disease of the pleura

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5
Q

Where does the malignancy in mesothelioma commonly metastasise to?

A

the contralateral lung and the peritoneum and usually affects the right lung more than the left

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6
Q

Asbestosis requires long term exposure to asbestos, what about mesothelioma?

A

occurs with SHORT-TERM exposure as well

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7
Q

What type of T cell drives asthma?

A

Th2

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8
Q

What are the three risk factors for an exacerbation of asthma?

A

a known diagnosis of asthma

viral infection

pollutants

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9
Q

What determines the severity of the asthma exacerbation? (The checklist for near fatal (1 requirement), life-threatening (4 requirements) and severe (2 requirements))

A

Near fatal- pCO2>6

Life-threatening- SpO2<92%/ pO2<8/ Cyanosis/ Hypotension

Severe- Respiratory rate>25/ HR>110

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10
Q

What are 4 investigations to be conducted in the event of an asthma exacerbation?

A

Peak flow expiratory volume-
- it is severe if <50% of the baseline and life-threatening if <33% of the baseline

ABG- assess the pO2 and pCO2
- a normal or severe pCO2 is very concerning

Inflammatory markers- there will be raised WCC and CRP if the cause is an infective trigger such as a virus

CXR- there will be HYPEREXPANSION

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11
Q

What is the immediate (3) and subsequent (2) management for an exacerbation of asthma?

and when can they be discharged?

A

Immediate-

1) Oxygen (aim for an SpO2 of 94-98%)
2) Nebulised Bronchodilators (SALBUTAMOL first and then IPRATROPIUM BROMIDE)
3) Corticosteroids (Prednisolone or IV hydrocortisone)

Subsequent-

1) IV Bronchodilator (Magnesium sulphate works)
2) Admission to ICU (for further bronchodilator treatment- SALBUTAMOL and AMINOPHYLLINE)

Discharge when PEFR>75%

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12
Q

What are the signs of asthma? (not an exacerbation but a general diagnosis)- there are 4 listed here

A

symptoms are worse at night and early morning

a DRY cough

wheeze and chest-tightness

dyspnoea and an expiratory wheeze

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13
Q

What are the 2 investigations which support a diagnosis of asthma?

A

FEV1/FVC <0.7

Fractional exhaled nitric oxide >40

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14
Q

What is the seven step management approach to stable asthma?

A

1) SABA

If SABA is not working or symptoms involve patients waking up at night OR occur more than 2 times a week-

2) SABA + low dose ICS
3) SABA + low dose ICS + LTRA
4) SABA + low dose ICS + LABA (+/- LTRA)
5) SABA + MART (which is basically just low dose ICS and LABA) (+/- LTRA)

6) SABA + MART (with higher ICS dose) (+/- LTRA)
or SABA + moderate dose ICS + LABA (+/- LTRA)

7) SABA + high dose ICS (+/- LTRA)
or SABA + theophylline or LAMA (+/- LTRA)

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15
Q

What are the four side effects of salbutamol?

A

Tachycardia
Palpitations
Headache
Tremor

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16
Q

What are some examples of ICS? (4)

A

Budesonide
Mometasone
Beclomethasone dipropionate
Fluticasone propionate

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17
Q

What are the four side effects of ICS (as asthma therapy)?

A

Sore throat
Cough
Oral candidiasis (thrush)
Stunted growth in children

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18
Q

What are two examples of LABA?

A

Salmeterol

Folmeterol

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19
Q

What are three examples of LTRA?

A

Montelukast
Zafirlukast
Pranlukast

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20
Q

What are the three side effects of LTRA?

A

Irritability
Akasthisia
Insomnia

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21
Q

What are the two sub-conditions that make up COPD?

A

Emphysema- loss of alveolar integrity due to an imbalance between proteases and protease-inhibitors (Alpha 1 antitrypsin)- this is triggered by chronic inflammation such as smoking

Bronchitis- mucus secretion which occurs secondary to ciliary dysfunction and increased size and number of goblet cells this leads to the destruction of the lung parenchyma and impairs gas exchange

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22
Q

What are the three risk factor for COPD?

A 
Smoking
Occupational exposure (dust, coal, cotton etc)
Alpha-1-antitrypsin deficiency
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23
Q

What are the 9 signs of COPD?

Plus 3 signs of exacerbation

A

Dyspnoea
Productive cough (may not always be)
Wheeze

BARREL CHEST
HYPER RESONANCE
Quiet breath sounds

TAR STAINING of fingers
PERIPHERAL CYANOSIS

POTENTIALLY SIGNS of COR PULMONALE- right heart failure due to a peripheral oedema caused by COPD

EXACERBATION-

  • SIGNIFICANT dyspnoea/ wheeze/ cough
  • Coarse crepitation
  • Pyrexia
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24
Q

What are the 7 investigations to be conducted on a COPD patient?

A

1) FEV1/FVC <0.7

2) CXR
- Flattened diaphragm
- Hyperinflation and bullae
- Check for lung cancer

3) FBC
- it can show CHRONIC HYPOXIA which can result in POLYCYTHAEMIA

4) BMI
5) A reduced TLCO
6) Serum alpha-antitrypsin levels
7) ECG to check for signs of right heart failure- RIGHT AXIS DEVIATION and RIGHT BUNDLE BRANCH BLOCK

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25
Q

What are the three things that should be done to manage COPD in all patients and the gold standard for COPD management based on their exacerbations per year and MRC score?

A

1) Smoking cessation (nicotine replacement with varenicline or bupropion)
2) Pulmonary rehabilitation- if functionally disabled (MRC is 3 or higher)
3) ONE OFF Pneumococcal vaccination and ANNUAL Influenza vaccination

1 or less exacerbation per year -

  • MRC is 1 or less= ANY bronchodilator
  • MRC is higher than 1= LABA or LAMA

2 or more exacerbations per year-

  • MRC is 1 or less= LAMA
  • MRC is higher than 1= LAMA or LAMA and LABA or LABA and ICS

LAMA- tiotropium
LABA- salmeterol
ICS- beclamethasone

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26
Q

What are the 4 signs of cor pulmonale?

A

Peripheral oedema
Raised JVP
Hepatosplenomegaly
Parasternal heave

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27
Q

What are the two therapies for cor pulmonale and what three medications should be avoided?

A

Loop diuretics and long term oxygen therapy

Avoid- ACE inhibitors, Alpha blockers, Calcium channel blockers

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28
Q

What are 3 extra therapies considered for COPD in addition to the LABA/ LAMA/ ICS?

A

Theophylline- offered after LABA etc. OR if the patient can’t tolerate inhaled medication

Oral prophylactic ANTIBIOTIC therapy (AZITHROMYCIN)

  • If patients do NOT smoke and have optimised treatments but STILL have exacerbations
  • BUT (3 things)
    1) Do a CT scan to eliminated bronchiectasis and other pathology
    2) Do a sputum culture to eliminate ATYPICAL infections and TB and ANTIBIOTIC-resistant organisms
    3) Do ECG to rule out long QT syndrome as ERYTHROMYCIN can prolong the QT interval

Long term oxygen therapy

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29
Q

What is the pathophysiology of cystic fibrosis?

A

Mutations in the CFTR gene. The CFTR protein is a chloride channel and it becomes dysfunctional. This leads to many systems being affected

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30
Q

How does the respiratory, gastrointestinal and cardiac systems get affected by the CFTR mutation?

A

Respiratory-

  • Dry airways and impaired clearance of mucus via cilia leads to COUGH/ DYSPNOEA and RECURRENT PNEUMONIA
  • There is an increased risk of bacterial colonisation via PSEUDONOMAN AERUGINOSA and STAPHYLOCOCCUS AUREUS
  • The chronic inflammatory response can lead to BRONCHIECTASIS

Gastrointestinal-

  • Thickened secretion in the bowels can lead to obstructions
  • Pancreatic insufficiency can occur due to the secretion of crucial enzymes being impaired and this leads to malabsorption
  • Liver cirrhosis can also occur due to thick biliary secretions blocking the bile duct leading to LIVER FIBROSIS/ CIRRHOSIS/ PORTAL HYPERTENSION

Cardiac-

  • Right heart failure due to pulmonary hypertension which can cause cor pulmonale
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31
Q

What are the 2 main tests used to diagnose cystic fibrosis and the genetic testing used?

A

Guthrie test- in neonates
Sweat test- in children and adults

Genetic testing- DELTA F508

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32
Q

What is the main sign of cystic fibrosis seen in adults and children and the signs seen in antenates (1), neonates (1), children (5) and adults (4)?

A

Clubbing is the most well-recognised sign

Antenates-
- Hyperechogenic bowel on ULTRASOUND

Neonates-
- Prolonged jaundice and Meconium ileus (children’s first poo is thick enough to block)

Children (Nose and GI)-

  • Nasal polyps and chronic sinusitis
  • Malabsorption
  • Pancreatitis
  • Portal Hypertension
  • Rectal Prolapse

Adults (Respiratory and Sexual)

  • Atypical asthma
  • Recurrent chest infections
  • Male infertility (absent vas deferens)
  • Female subfertility
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33
Q

How do you manage the respiratory symptoms of cystic fibrosis? (6)

A

Airway clearance- chest physiotherapy and postural drainage

Bronchodilator (inhaled SALBUTAMOLE)

Mucoactive agents

  • rhDNase
  • hypertonic sodium chloride
  • lumacaftor/ ivacaftor

Immunomodulation

  • Azathioprine
  • then oral CORTICOSTEROIDS

Antibiotics for treatment of pneumonia

Lung or heart transplantation

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34
Q

How do you manage the gastrointestinal symptoms of cystic fibrosis? (5)

A

High calorie/ high fat diet

Vitamin ADEK for pancreatic insufficiency

CREON for pancreatic insufficiency (contains the necessary enzymes)

PPI to help with the absorption of CREON

IF ABNORMAL LFTs- Ursodeoxycholic acid

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35
Q

Causes of Upper Zone Fibrosis? (7)

A 
Sarcoidosis
Ankylosing Spondylitis
Tuberculosis
Cystic Fibrosis
Hypersensitivity Pneumonitis

Coal worker’s pneumoconiosis
Silicosis

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36
Q

Causes of Lower Zone Fibrosis? (4)

A

Drug induced (4)

  • Amiodarone
  • Nitrofurantoin
  • Bleomycin
  • Methotrexate

Idiopathic pulmonary fibrosis

Most connective tissue disorders (SLE for example but not Ankylosing Spondylitis)

Asbestosis

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37
Q

What are the 5 signs of idiopathic pulmonary fibrosis?

A 
Progressive Dyspnoea
NON-PRODUCTIVE cough
Clubbing
Bibasal end-inspiratory crackles in lower zone
Malaise
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38
Q

What 3 investigations should be done if idiopathic pulmonary fibrosis is suspected?

A

Chest X ray- bilateral reticulonodular shadowing- GROUND GLASS which progresses to HONEYCOMBING

High resolution CT THORAX- increased reticulation and HONEYCOMBING

Spirometry- restrictive lung condition-

  • FEV1- normal or low
  • FVC- very low
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39
Q

What is the management of idiopathic pulmonary fibrosis? (3)

A

If FVC is 50-80% of predicted- ANTIFIBROTICS- PIRFENIDONE or NINTEDANIB

Supportive treatment-

  • Pulmonary rehabilitation
  • Vaccinate against PNEUMOCOCCUS and INFLUENZA
  • If patient is breathless on exertion- AMBULATORY OXYGEN THERAPY and/or LONG TERM OXYGEN THERAPY

Lung transplantation is also an option

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40
Q

What are the 2 main complications of pulmonary fibrosis?

A

Pulmonary hypertension

Cor pulmonale

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41
Q

What is Klebsiella and what 2 conditions is it associated with?

What 2 conditions is klebsiella pneumonia most commonly found in?

A

A gram negative anaerobic rod bacteria

Associated with Pneumonia and UTIs

Found commonly in alcoholics and diabetic patients (usually after aspiration)

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42
Q

Which lobes are usually affected in Klebsiella pneumonia and what kind of sputum is produced?

A

upper lobes

redcurrant jelly sputum

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43
Q

What are the indications for long-term oxygen therapy in COPD?

A

If they DON’T smoke and

if ABG on at least 2 occasions 3 weeks apart-
- PaO2< 7.3 kPa

or

- PaO2 between 7.3kPa and 8kPa
   AND
           - Secondary polycythaemia
           - Peripheral oedema
           - Pulmonary hypertension
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44
Q

Are the majority of lung cancer cases small cell or non small cell?

A

85% of cases and non small cell lung cancers

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45
Q

What are the three types of non small cell lung cancer?

A

adenocarcinoma, squamous cell, large cell

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46
Q

What is special about alveolar cell tumours?

A

They are not related to smoking

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47
Q

Which lung cancers have central lesions and which ones have peripheral lesions?

A

Central- small cell/ squamous cell

Peripheral- adeno/ large cell

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48
Q

Which lung cancer type has the lowest link to smoking?

A

Adenocarcinoma (which is also the most common)

49
Q

What are the paraneoplastic syndromes for small cell lung cancer (3)?

A

SIADH (which leads to hyponatraemia)

Ectopic ACTH production (which leads to Cushing’s)

Lambert-Eaton-Myasthenic Syndrome

50
Q

What are the paraneoplastic syndromes for adenocarcinoma lung cancer (2)?

A

Hypertrophic pulmonary osteoarthropathy (which has CLUBBING)

Gynaecomastia

51
Q

What are the paraneoplastic syndromes for squamous cell lung cancer (2)?

A

Hypertrophic pulmonary osteoarthropathy (which has CLUBBING)

PTHrP- Hypercalcaemia

52
Q

What are the paraneoplastic syndromes for large cell lung cancer (2)?

A

Hypertrophic pulmonary osteoarthropathy (which has CLUBBING)

Ectopic Beta-HCG production

53
Q

Ectopic ACTH production by small cell lung cancer is less commonly associated with Cushing’s, what is it commonly associated with (4)?

And what can it result in?

A

Hyperglycaemia
Hypertension
Hypokalaemic alkalosis
Muscle Weakness

results in bilateral adrenal hyperplasia

54
Q

What is hypertrophic pulmonary osteoarthropathy?

A

It causes inflammation of the bones and joints of the wrists and ankles and also causes clubbing of the fingers and toes

it is most commonly associated with ADENOCARCINOMAS

55
Q

What are the 6 signs of lung cancer?

A

Persistent cough (with or without haemoptysis)

Dyspnoea

Reduced breath sounds and a fixed monophonic wheeze

Stony dull percussions due to pleural effusion

Supraclavicular or persistent cervical lymphadenopathy

Constitutional symptoms (night sweats, lethargy, fever, weight loss and anorexia)

56
Q

What are the extrapulmonary manifestations of a lung cancer? (3)

A

Clubbing (which is strongly associated with the squamous cell carcinoma)

Facial plethora and swelling (as a result of superior vena cava obstruction)

Hoarseness (due to recurrent laryngeal nerve palsy)- due to PANCOAST TUMOR

57
Q

What 5 investigations are conducted for lung cancer?

A

Chest X ray (first line)- may be hilar enlargement, pleural effusion or circular opacities BUT may be normal

CT chest with contrast- if abnormal CXR or normal CXR but persistent symptoms

PET-CT- if the CT shows a malignancy then this is done to stage the disease

Biopsy

FBC- to see whether there is ANAEMIA and THROMBOCYTOPAENIA

58
Q

How is lung cancer managed? For both small cell and non-small cell

A

Smoking cessation first

Small cell-
- if the disease is limited (confined to the ipsilateral haemothorax)- chemotherapy with platinum-based agents like CISPLATIN

  • if the disease is extensive- chemoradiotherapy with platinum based agents or palliative chemotherapy

Non-small cell-

  • non metastatic (stage 1-3a)
    1) surgery with adjuvant chemotherapy and patients are given MEDIASTINOSCOPY preoperatively
    2) Or curative radical radiotherapy
  • metastatic (stage 3b and above)
    1) palliative treatment with immunotherapy, radiotherapy and chemotherapy
59
Q

What are the 7 contraindications to surgery in non-small cell carcinomas?

A

Frail

Metastatic disease (stage 3b or 4)

FEV1< 1.5 for lobectomy and <2.0 for pneumonectomy

Malignant pleural effusion

Tumour is near the hilum

Superior vena cava obstruction

Vocal cord paralysis

60
Q

What are the 4 causes of increased and decreased TLCO (transfer factor for CO)

A

INCREASED-

  • Asthma (or normal)
  • Polycythaemia
  • Pulmonary haemorrhage
  • Left-to-right shunt

DECREASED-

  • COPD
  • Restrictive lung diseases
  • Pulmonary embolism
  • Anaemia
61
Q

What are 3 obstructive disorders and what are the expected FEV1, FVC, FEV1/ FVC and TLC values?

A

COPD, Asthma, Bronchiectasis

FEV1- reduced
FVC- normal
FEV1/FVC <0.7
TLC- normal

62
Q

What are 4 restructive disorders and what are the expected FEV1, FVC, FEV1/ FVC and TLC values?

A

Interstitial lung disease, Idiopathic pulmonary fibrosis, Pneumoconiosis, Sarcoidosis

FEV1- reduced or normal
FVC- reduced
FEV1/FVC- normal or raised (cos denominator is low)
TLC- reduced

63
Q

What is the pathophysiology of Mesothelioma?

A

It is the malignancy of the mesothelial cells of the pleura

The main cause of this is asbestos exposure which stimulates neutrophil and macrophage activity which generates reactive oxygen and nitrogen species. This causes DNA damage and increases the risk of cancer.

64
Q

What are the 7 signs of Mesothelioma?

A

Clubbing

Shortness of breath

Pleural effusion (so stony dull percussion)

Pleuritic chest pain

Ascites (if there is peritoneal disease)

Reduced breath sounds

Constitutional symptoms (night sweats, weight loss, lethargy, fatigue)

65
Q

What are the 4 investigations conducted for Mesothelioma?

A

CXR (4) - unilateral pleural effusion/ reduced lung volume/ pleural thickening/ lower zone interstitial fibrosis

Contrast-enhanced CT of chest- pleural thickening/ pleural plaques and enlarged lymph nodes

Pleural aspiration if there is evidence of Pleural Effusion (it will be exudative)

Calretinin, Nuclear WT1 and Keratins 5/6 are positive

66
Q

What is the management of Mesothelioma?

A

Surgery

Then Chemotherapy with CISPLATIN and PEMETREXED

67
Q

Causes of transudate pleural effusion and 5 examples

A

Increased hydrostatic pressure or decreased oncotic pressure

1) Congestive heart failure
2) Hypoalbuminaemia (causes include chronic liver disease/ nephrotic syndrome/ malabsorption)
3) Hypothyroidism
4) Peritoneal dialysis
5) Meigs Syndrome

68
Q

Causes of exudate pleural effusion and 6 examples

A

Infection, inflammation or malignancy

1) Pneumonia is the most common, then TB then subphrenic abscess
2) Malignancy (lung cancer, mesothelioma, lymphoma, metastasis)
3) Pulmonary embolism
4) Severe Pancreatitis
5) Autoimmune and connective tissue disorders (SLE, rheumatoid pleurisy, EOSINOPHILIC GRANULAMATOSIS with POLYANGIITIS)
6) Dressler’s Syndrome

69
Q

5 signs of Pleural Effusion

A

Shortness of breath

Reduced chest expansion and breath sounds on the AFFECTED SIDE

Pleuritic chest pain (seen in EXUDATIVE DUE TO IRRITATION)

Symptoms of the underlying cause (peripheral oedema if heart failure, ascites if liver cirrhosis and productive cough with fever if pneumonia)

Pleural friction rub and bronchial breathing in the most superior aspect of the pleural effusion

70
Q

5 causes of low pH (<7.3) of pleural fluid

A

Complicated parapneumonic effusion

Empyema

Malignancy

Rheumatoid pleurisy

Tuberculosis

71
Q

Causes of heavy blood staining in pleural fluid

A

Malignancy
Mesothelioma
TB
Pulmonary embolism

72
Q

What is a parapneumonic effusion?

A

Pleural effusion that occurs secondary to pneumonia or lung abscess

73
Q

3 causes of low glucose in pleural effusion

A

rheumatoid pleurisy/ malignancy/ tuberculosis

74
Q

2 causes of raised amylase in pleural fluid

A

pancreatitis and oesophageal rupture

75
Q

Management of pleural effusion

non-malignant and infective

A

non-malignant-

  • treat the underlying cause (loop diuretics for congestive heart failure)
  • thoracentesis for symptomatic effusion
  • pleurodesis, recurrent aspiration and indwelling pleural catheter for recurrent effusions

infective-

  • chest tube drainage if (4)
    1) purulent or cloudy pleural fluid
    2) positive gram stain
    3) pH<7.2
    4) loculated pleural fluid (compartmentalised)
76
Q

What is pneumoconiosis? (pathophysiology)

A

It is interstitial fibrosis secondary to occupational exposure

dust particles that are inhaled reach the terminal bronchioles and are eaten by interstitial and alveolar macrophages and are then expelled as mucus

but in people who are exposed for a long time, the macrophages accumulate in the alveoli and cause LUNG TISSUE DAMAGE

77
Q

What is the only form of pneumoconiosis which has lower zone fibrosis?

A

Asbestosis

78
Q

What causes coal worker’s pneumoconiosis?

and silicosis and berylliosis and asbestosis?

A

Coal worker’s pneumoconiosis- carbon

silicosis- sand blasters, quarry workers

berylliosis- aerospace industry

asbestosis- construction workers, plumbers and shipyard workers

79
Q

What are 6 signs of pneumoconiosis?

A

Clubbing

Fine crackles

Dry cough

Wheezing

Haemoptysis

Weight loss

80
Q

What does simple pneumoconiosis eventually become?

A

Simple pneumoconiosis (usually asymptomatic) may become progressive massive fibrosis and increases the risk of COPD

Progressive massive fibrosis is common in coal worker’s pneumoconiosis and silicosis and involves the production of BLACK SPUTUM

81
Q

What are the two investigations conducted in patients suspected to have pneumoconiosis?

A

CXR- shows fibrosis and calcification of hilar lymph nodes (egg shell calcification)

Spirometry- shows a RESTRICTIVE LUNG DISEASE with an FEV1/FVC>0.7 and a low TLCO

82
Q

What is the management of pneumoconiosis?

A

It is incurable and management is largely conservative

it involves smoking cessation, pulmonary rehabilitation, providing oxygen if hypoxic and

GIVING CORTICOSTEROIDS in BERYLLIOSIS

83
Q

Three bacteria associated with Community Acquired Pneumonia

A

Streptococcus pneumoniae (most common)

Haemophilus influenzae (associated with COPD)

Staphylococcus aureus

84
Q

Three bacteria associated with Atypical Pneumonia

A

Mycoplasma pneumoniae (associated with haemolytic anaemia and erythema multiforme)

Legionella pneumophilia (history of exposure to water source (air conditioning))- HYPONATRAEMIA, LYMPHOPENIA and deranged LFTs

Chalmydia psittaci- exposure to birds

85
Q

Bacteria associated with Hospital Acquired Pneumonia

A

Gram negative bacteria and staphylococcus aureus

86
Q

What is Aspiration Pneumonia? What is the bacteria associated with Aspiration Pneumonia and what is it usually associated with?

A

Caused due to the inhalation of oropharyngeal content

Associated with Klebsiella

Associated with-
1- Poor swallow (Parkinson's Disease)
2- Poor dental hygeine
3- Impaired consciousness
4- Prolonged hospitalisation or surgery
87
Q

What microorganism is associated with fungal pneumonia and what disease is it associated with?

A

Pneumocystis jirovecci, associated with HIV

88
Q

Which bacteria is associated with IV drug use and causes Pneumonia

A

Staphylococcus aureus

89
Q

What are the 6 signs of Pneumonia?

A

Productive cough

Reduced breath sounds, coarse crepitations, bronchial breathing

PLEURITIC CHEST PAIN

Hypoxia

Tachycardia

PYREXIA

90
Q

What are the 3 investigations for pneumonia?

A

CXR- consolidation caused by inflammatory exudate- not seen in atypical pneumonia

FBC- LEUKOCYTOSIS

CRP- raised

91
Q

What is CURB 65?

A 
Confusion
Urea>7
Respiratory rate>30 per minute
Blood pressure< 90 systolic
over 65 years old
92
Q

What is the management for community acquired pneumonia?

A

CURB= 0 or 1
- Oral amoxicillin or doxycycline/ clarithromycin if they are allergic to penicillin

CURB= 2
- Amoxicillin and add clarithromycin if atypical bacteria is suspected

CURB= 3 or higher
- IV coamoxiclav and clarithromycin

93
Q

What is the management for hospital acquired pneumonia?

A

Low severity- oral coamoxiclav

High severity- broad spectrum antibiotic like IV TAZOCIN or CETRIAXONE

94
Q

What are the 5 risk factors for pneumothorax?

A

Smoking

Rheumatoid arthritis

Homocysteinuria

Diving or flying

Marfan Syndrome

95
Q

What are the 6 signs of pneumothorax?

A

Sudden onset pleuritic chest pain
Sudden onset dyspnoea

Hyperresonance on the affected side
Reduced breath sounds on the affected side

Hyperexpansion on the affected side

Contralateral tracheal deviation

96
Q

What is seen in the chest xray of a pneumothorax?

A

mediastinal shift and loss of lung markings on ipsilateral side

97
Q

Management of spontaneous and tension pneumothorax

A

spontaneous- aspiration alongside O2

emergency needle compression alongside O2
chest drain needed after aspiration

SURGICAL MANAGEMENT if

  • bilateral pneumothorax
  • pregnancy
  • profession involves pilot/ diving etc
98
Q

What does pulmonary embolism commonly cause?

A

It causes strain on the right ventricle and result in cor pulmonale if it is massive enough

99
Q

What are the 7 signs of pulmonary embolism?

A

pleuritic chest pain

haemoptysis or cough

dyspnoea

hypoxia

FEVER

swollen cough maybe cos of DVT

hypotension

100
Q

What are the 4 common clinical features of pulmonary embolism?

A

tachypnoea
tachycardia
crackles
fever

101
Q

What are 2 signs to look out for in pulmonary embolism?

A

Right parasternal heave- suggests right ventricular strain

Raised JVP- suggests COR PULMONALE

102
Q

What is the Wells Score limit for pulmonary embolism?

A

4 (above is PE)

103
Q

What are the 5 investigations that should be conducted in pulmonary embolism?

A

CXR- may be normal but usually there is a WEDGE-SHAPED OPACIFICATION

ECG (3)- sinus tachycardia, RBBB and right axis deviation (right heart strain), S1Q3T3 (Large S waves in 1, large Q wave in 3 and inverted T wave in 3)

CTPA or D-DIMER- CTPA if Wells>4- V/Q scan instead in allergy or renal impairment (if creatinine<30), D-DIMER if 4 or less

All patients with unprovoked PE should have a full set of blood tests

Investigations for thrombophilia- antiphospholipid antibodies if there is a plan to STOP COAGULATION and THROMBOPHILIA SCREEN is there is a plan to stop coagulation and they have a family member with DVT

104
Q

What is the treatment for pulmonary embolism?

A

Massive PE- thrombolysis with ALTEPLASE
- Massive if haemodynamic instability (BP<90)

Non-massive PE- anticoagulation
- if no renal impairment- Apixaban or Rivaroxaban or LMWH or LMWH and Warfarin

  • if renal impairment (creatine clearance<15)- LMWH or unfractionated Heparin (you can add warfarin until INR is 2 and then just give warfarin)
  • active cancer- DOAC (like Rivaroxaban) or LMWH
105
Q

What organism causes TB?

A

Mycobacterium Tuberculosis

106
Q

What are 5 signs of TB?

A

Haemoptysis

Maybe crackles, but auscultation may be normal

Clubbing if long standing

Dyspnoea

Systemic symptoms- Fever, Night Sweats, Weight loss, Lymphadenopathy

107
Q

What is the screening used to identify Latent TB in asymptomatic patients at risk of TB?

A

Mantoux Screening

108
Q

What are 4 investigations conducted in TB?

A

CXR- Ghon Complex in Latent TB, Upper Zone Lesions in Active TB

Microbiology- Ziel-Neelsen stain and Mycobacterium culture

NAAT test

HIV and HEPATITIS status

109
Q

How do you manage TB?

A

Rifampicin, Isoniazid, Pyrazinamide and Ethambutol for 2 months and then Rifampicin and Isoniazid for 4 months

If the CNS is affected (TB meningitis)- add DEXAMETHASONE or PREDNISOLONE

110
Q

What are the 3 complications of TB?

A

Pneumothorax
Empyema
Bronchiectasis

111
Q

What are the 3 risk factors for Sarcoidosis?

A

Afro-Caribbean ethnicity
Scandinavian ethnicity
Female gender

112
Q

What are the 9 symptoms of Sarcoidosis?

A

Swinging fever

Non-productive cough

Dyspnoea

Cervical and submandibular lymphadenopathy

Lupus pernio (a lupus-like rash)

Erythema nodosum

POLYARTHRALGIA

Uveitis (red-eye) and photophobia

Weight loss

113
Q

What are the 6 main investigations of Sarcoidosis?

A

ACE is raised (but not always)

Hypercalcaemia may or may not be present

Inflammatory markers may be raised (ESR)

CXR (hilar lymphadenopathy or bilateral infiltrates)

CT chest (ground glass= reversible, cystic distortion= irreversible)

ECG= heart block

114
Q

What indicates the need for steroids in Sarcoidosis management?

A

Hypercalcaemia OR extrapulmonary involvement

115
Q

How is the pulmonary disease in Sarcoidosis managed?

A

First line- Corticosteroids (inhaled budesonide and oral prednisolone)

Second line- Immunosuppressants (methotrexate or azathioprine)

Third line- lung transplantation

Acute respiratory failure=> ORAL or IV CORTICOSTEROIDS

(Extrapulmonary management- first line- corticosteroids and second line- immunosuppressants)

116
Q

How does Rifampicin work and what are its side effects?

A

It inhibits bacterial RNA polymerase

Side effects- hepatitis/ orange sweat, tears and urine/ flu-like symptoms

117
Q

How does Isoniazid work and what are its side effects?

A

It inhibits the mycobacterial cell wall

Side effects- hepatitis/ peripheral neuropathy (PREVENT with PYRIDOXINE)/ agranulocytosis

118
Q

How does Pyrazinamide work and what are its side effects?

A

It is converted to Pyrazinoic Acid which inhibits fatty acid synthase

Side effects- hepatitis/ GOUT (due to hyperuricaemia)/ arthralgia and myalgia

119
Q

How does Ethambutol work and what are its side effects?

A

It inhibits Arabinosyl Transferase

Side effects- optic neuritis/ dose readjustment needed if there is renal impairment

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