Respiratory Flashcards
Pathophysiology of Asbestos-related Lung Disease
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
What 2 pleural features are seen in asbestos-related lung disease?
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
Is asbestosis restrictive or obstructive? and are the lower or upper zones predominantly affected?
restrictive disease and the lower zones are predominantly affected in asbestosis
What is mesothelioma?
it is a form of asbestos-related lung disease. it is a malignant disease of the pleura
Where does the malignancy in mesothelioma commonly metastasise to?
the contralateral lung and the peritoneum and usually affects the right lung more than the left
Asbestosis requires long term exposure to asbestos, what about mesothelioma?
occurs with SHORT-TERM exposure as well
What type of T cell drives asthma?
Th2
What are the three risk factors for an exacerbation of asthma?
a known diagnosis of asthma
viral infection
pollutants
What determines the severity of the asthma exacerbation? (The checklist for near fatal (1 requirement), life-threatening (4 requirements) and severe (2 requirements))
Near fatal- pCO2>6
Life-threatening- SpO2<92%/ pO2<8/ Cyanosis/ Hypotension
Severe- Respiratory rate>25/ HR>110
What are 4 investigations to be conducted in the event of an asthma exacerbation?
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
What is the immediate (3) and subsequent (2) management for an exacerbation of asthma?
and when can they be discharged?
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%
What are the signs of asthma? (not an exacerbation but a general diagnosis)- there are 4 listed here
symptoms are worse at night and early morning
a DRY cough
wheeze and chest-tightness
dyspnoea and an expiratory wheeze
What are the 2 investigations which support a diagnosis of asthma?
FEV1/FVC <0.7
Fractional exhaled nitric oxide >40
What is the seven step management approach to stable asthma?
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)
What are the four side effects of salbutamol?
Tachycardia
Palpitations
Headache
Tremor
What are some examples of ICS? (4)
Budesonide
Mometasone
Beclomethasone dipropionate
Fluticasone propionate
What are the four side effects of ICS (as asthma therapy)?
Sore throat
Cough
Oral candidiasis (thrush)
Stunted growth in children
What are two examples of LABA?
Salmeterol
Folmeterol
What are three examples of LTRA?
Montelukast
Zafirlukast
Pranlukast
What are the three side effects of LTRA?
Irritability
Akasthisia
Insomnia
What are the two sub-conditions that make up COPD?
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
What are the three risk factor for COPD?
Smoking Occupational exposure (dust, coal, cotton etc) Alpha-1-antitrypsin deficiency
What are the 9 signs of COPD?
Plus 3 signs of exacerbation
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
What are the 7 investigations to be conducted on a COPD patient?
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
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?
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
What are the 4 signs of cor pulmonale?
Peripheral oedema
Raised JVP
Hepatosplenomegaly
Parasternal heave
What are the two therapies for cor pulmonale and what three medications should be avoided?
Loop diuretics and long term oxygen therapy
Avoid- ACE inhibitors, Alpha blockers, Calcium channel blockers
What are 3 extra therapies considered for COPD in addition to the LABA/ LAMA/ ICS?
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
What is the pathophysiology of cystic fibrosis?
Mutations in the CFTR gene. The CFTR protein is a chloride channel and it becomes dysfunctional. This leads to many systems being affected
How does the respiratory, gastrointestinal and cardiac systems get affected by the CFTR mutation?
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
What are the 2 main tests used to diagnose cystic fibrosis and the genetic testing used?
Guthrie test- in neonates
Sweat test- in children and adults
Genetic testing- DELTA F508
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)?
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
How do you manage the respiratory symptoms of cystic fibrosis? (6)
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
How do you manage the gastrointestinal symptoms of cystic fibrosis? (5)
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
Causes of Upper Zone Fibrosis? (7)
Sarcoidosis Ankylosing Spondylitis Tuberculosis Cystic Fibrosis Hypersensitivity Pneumonitis
Coal worker’s pneumoconiosis
Silicosis
Causes of Lower Zone Fibrosis? (4)
Drug induced (4)
- Amiodarone
- Nitrofurantoin
- Bleomycin
- Methotrexate
Idiopathic pulmonary fibrosis
Most connective tissue disorders (SLE for example but not Ankylosing Spondylitis)
Asbestosis
What are the 5 signs of idiopathic pulmonary fibrosis?
Progressive Dyspnoea NON-PRODUCTIVE cough Clubbing Bibasal end-inspiratory crackles in lower zone Malaise
What 3 investigations should be done if idiopathic pulmonary fibrosis is suspected?
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
What is the management of idiopathic pulmonary fibrosis? (3)
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
What are the 2 main complications of pulmonary fibrosis?
Pulmonary hypertension
Cor pulmonale
What is Klebsiella and what 2 conditions is it associated with?
What 2 conditions is klebsiella pneumonia most commonly found in?
A gram negative anaerobic rod bacteria
Associated with Pneumonia and UTIs
Found commonly in alcoholics and diabetic patients (usually after aspiration)
Which lobes are usually affected in Klebsiella pneumonia and what kind of sputum is produced?
upper lobes
redcurrant jelly sputum
What are the indications for long-term oxygen therapy in COPD?
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
Are the majority of lung cancer cases small cell or non small cell?
85% of cases and non small cell lung cancers
What are the three types of non small cell lung cancer?
adenocarcinoma, squamous cell, large cell
What is special about alveolar cell tumours?
They are not related to smoking
Which lung cancers have central lesions and which ones have peripheral lesions?
Central- small cell/ squamous cell
Peripheral- adeno/ large cell
Which lung cancer type has the lowest link to smoking?
Adenocarcinoma (which is also the most common)
What are the paraneoplastic syndromes for small cell lung cancer (3)?
SIADH (which leads to hyponatraemia)
Ectopic ACTH production (which leads to Cushing’s)
Lambert-Eaton-Myasthenic Syndrome
What are the paraneoplastic syndromes for adenocarcinoma lung cancer (2)?
Hypertrophic pulmonary osteoarthropathy (which has CLUBBING)
Gynaecomastia
What are the paraneoplastic syndromes for squamous cell lung cancer (2)?
Hypertrophic pulmonary osteoarthropathy (which has CLUBBING)
PTHrP- Hypercalcaemia
What are the paraneoplastic syndromes for large cell lung cancer (2)?
Hypertrophic pulmonary osteoarthropathy (which has CLUBBING)
Ectopic Beta-HCG production
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?
Hyperglycaemia
Hypertension
Hypokalaemic alkalosis
Muscle Weakness
results in bilateral adrenal hyperplasia
What is hypertrophic pulmonary osteoarthropathy?
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
What are the 6 signs of lung cancer?
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)
What are the extrapulmonary manifestations of a lung cancer? (3)
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
What 5 investigations are conducted for lung cancer?
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
How is lung cancer managed? For both small cell and non-small cell
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
What are the 7 contraindications to surgery in non-small cell carcinomas?
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
What are the 4 causes of increased and decreased TLCO (transfer factor for CO)
INCREASED-
- Asthma (or normal)
- Polycythaemia
- Pulmonary haemorrhage
- Left-to-right shunt
DECREASED-
- COPD
- Restrictive lung diseases
- Pulmonary embolism
- Anaemia
What are 3 obstructive disorders and what are the expected FEV1, FVC, FEV1/ FVC and TLC values?
COPD, Asthma, Bronchiectasis
FEV1- reduced
FVC- normal
FEV1/FVC <0.7
TLC- normal
What are 4 restructive disorders and what are the expected FEV1, FVC, FEV1/ FVC and TLC values?
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
What is the pathophysiology of Mesothelioma?
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.
What are the 7 signs of Mesothelioma?
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)
What are the 4 investigations conducted for Mesothelioma?
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
What is the management of Mesothelioma?
Surgery
Then Chemotherapy with CISPLATIN and PEMETREXED
Causes of transudate pleural effusion and 5 examples
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
Causes of exudate pleural effusion and 6 examples
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
5 signs of Pleural Effusion
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
5 causes of low pH (<7.3) of pleural fluid
Complicated parapneumonic effusion
Empyema
Malignancy
Rheumatoid pleurisy
Tuberculosis
Causes of heavy blood staining in pleural fluid
Malignancy
Mesothelioma
TB
Pulmonary embolism
What is a parapneumonic effusion?
Pleural effusion that occurs secondary to pneumonia or lung abscess
3 causes of low glucose in pleural effusion
rheumatoid pleurisy/ malignancy/ tuberculosis
2 causes of raised amylase in pleural fluid
pancreatitis and oesophageal rupture
Management of pleural effusion
non-malignant and infective
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)
What is pneumoconiosis? (pathophysiology)
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
What is the only form of pneumoconiosis which has lower zone fibrosis?
Asbestosis
What causes coal worker’s pneumoconiosis?
and silicosis and berylliosis and asbestosis?
Coal worker’s pneumoconiosis- carbon
silicosis- sand blasters, quarry workers
berylliosis- aerospace industry
asbestosis- construction workers, plumbers and shipyard workers
What are 6 signs of pneumoconiosis?
Clubbing
Fine crackles
Dry cough
Wheezing
Haemoptysis
Weight loss
What does simple pneumoconiosis eventually become?
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
What are the two investigations conducted in patients suspected to have pneumoconiosis?
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
What is the management of pneumoconiosis?
It is incurable and management is largely conservative
it involves smoking cessation, pulmonary rehabilitation, providing oxygen if hypoxic and
GIVING CORTICOSTEROIDS in BERYLLIOSIS
Three bacteria associated with Community Acquired Pneumonia
Streptococcus pneumoniae (most common)
Haemophilus influenzae (associated with COPD)
Staphylococcus aureus
Three bacteria associated with Atypical Pneumonia
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
Bacteria associated with Hospital Acquired Pneumonia
Gram negative bacteria and staphylococcus aureus
What is Aspiration Pneumonia? What is the bacteria associated with Aspiration Pneumonia and what is it usually associated with?
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
What microorganism is associated with fungal pneumonia and what disease is it associated with?
Pneumocystis jirovecci, associated with HIV
Which bacteria is associated with IV drug use and causes Pneumonia
Staphylococcus aureus
What are the 6 signs of Pneumonia?
Productive cough
Reduced breath sounds, coarse crepitations, bronchial breathing
PLEURITIC CHEST PAIN
Hypoxia
Tachycardia
PYREXIA
What are the 3 investigations for pneumonia?
CXR- consolidation caused by inflammatory exudate- not seen in atypical pneumonia
FBC- LEUKOCYTOSIS
CRP- raised
What is CURB 65?
Confusion Urea>7 Respiratory rate>30 per minute Blood pressure< 90 systolic over 65 years old
What is the management for community acquired pneumonia?
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
What is the management for hospital acquired pneumonia?
Low severity- oral coamoxiclav
High severity- broad spectrum antibiotic like IV TAZOCIN or CETRIAXONE
What are the 5 risk factors for pneumothorax?
Smoking
Rheumatoid arthritis
Homocysteinuria
Diving or flying
Marfan Syndrome
What are the 6 signs of pneumothorax?
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
What is seen in the chest xray of a pneumothorax?
mediastinal shift and loss of lung markings on ipsilateral side
Management of spontaneous and tension pneumothorax
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
What does pulmonary embolism commonly cause?
It causes strain on the right ventricle and result in cor pulmonale if it is massive enough
What are the 7 signs of pulmonary embolism?
pleuritic chest pain
haemoptysis or cough
dyspnoea
hypoxia
FEVER
swollen cough maybe cos of DVT
hypotension
What are the 4 common clinical features of pulmonary embolism?
tachypnoea
tachycardia
crackles
fever
What are 2 signs to look out for in pulmonary embolism?
Right parasternal heave- suggests right ventricular strain
Raised JVP- suggests COR PULMONALE
What is the Wells Score limit for pulmonary embolism?
4 (above is PE)
What are the 5 investigations that should be conducted in pulmonary embolism?
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
What is the treatment for pulmonary embolism?
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
What organism causes TB?
Mycobacterium Tuberculosis
What are 5 signs of TB?
Haemoptysis
Maybe crackles, but auscultation may be normal
Clubbing if long standing
Dyspnoea
Systemic symptoms- Fever, Night Sweats, Weight loss, Lymphadenopathy
What is the screening used to identify Latent TB in asymptomatic patients at risk of TB?
Mantoux Screening
What are 4 investigations conducted in TB?
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
How do you manage TB?
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
What are the 3 complications of TB?
Pneumothorax
Empyema
Bronchiectasis
What are the 3 risk factors for Sarcoidosis?
Afro-Caribbean ethnicity
Scandinavian ethnicity
Female gender
What are the 9 symptoms of Sarcoidosis?
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
What are the 6 main investigations of Sarcoidosis?
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
What indicates the need for steroids in Sarcoidosis management?
Hypercalcaemia OR extrapulmonary involvement
How is the pulmonary disease in Sarcoidosis managed?
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)
How does Rifampicin work and what are its side effects?
It inhibits bacterial RNA polymerase
Side effects- hepatitis/ orange sweat, tears and urine/ flu-like symptoms
How does Isoniazid work and what are its side effects?
It inhibits the mycobacterial cell wall
Side effects- hepatitis/ peripheral neuropathy (PREVENT with PYRIDOXINE)/ agranulocytosis
How does Pyrazinamide work and what are its side effects?
It is converted to Pyrazinoic Acid which inhibits fatty acid synthase
Side effects- hepatitis/ GOUT (due to hyperuricaemia)/ arthralgia and myalgia
How does Ethambutol work and what are its side effects?
It inhibits Arabinosyl Transferase
Side effects- optic neuritis/ dose readjustment needed if there is renal impairment
