Respiratory Flashcards

1
Q

What is tuberculosis?

A

an infectious disease caused by the mycobacterium tuberculosis bacteria

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2
Q

What is the most common cause of TB?

A

mycobacterium tuberculosis is the most common causative organism and is an aerobic acid-fast bacilli which is turned bright red against a blue background using the Ziehl-Neelson stain

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3
Q

What are some other mycobacteria which cause TB?

A

M. africans
M. microtis
M.bovis

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4
Q

What are the risk factors for TB?

A

Immunocompromised (e.g. HIV or immunosuppressive meds)
Close contacts with TB
Recent travel or immigration from areas of high TB prevalence
People with relatives or close contacts from countries with a high rate of TB
Homeless people, drug users, alcoholics
IVDU
Older age

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5
Q

What is active TB?

A

active infection in various areas within the body

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6
Q

What is latent TB?

A

where the immune system encapsulates sites of infection and stops the progression of disease

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7
Q

What is miliary TB>

A

severe, disseminated disease when the immune system is unable to control the spread/progression

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8
Q

What is extrapulmonary TB?

A

When infection spreads outside of the lungs (most common site of infection) to lymph nodes, pleura, CNS, pericardium, GI system, GU system, bones + joints, skin (cutaneous TB)

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9
Q

What is the immune response to TB?

A
  1. TB phagocytosed but resist killing –> formation of granulomas
  2. T cells are recruited and central region of granuloma undergoes caseating necrosis (primary Ghon focus, in upper parts of the lung)
  3. Ghon focus spreads to nearby lymph nodes –> Ghon complex (focus + lymph node spread)
  4. in most cases, infection is contained within granulomas –> latent TB
  5. If TB spreads systemically –> miliary TB
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10
Q

What are the key presentation sof TB?

A

chronic, gradual onset of symptoms
lethargy
fever or night sweats
weight loss
cough +/- haemoptysis
lymphadenopathy
erythema nodosum
spinal pain in spinal TB (Pott’s disease of spine)

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11
Q

What are the investigations for TB?

A

1st line: Purified Protein Derivative (PPD) - intradermal skin test which looks for previous immune response to TB
GS: Interferon Gamma Release Assay
Other: CXR , cultures

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12
Q

What are the CXR signs of primary TB?

A

patchy consolidation, pleural effusions and hilar lymphadenopathy

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13
Q

What are the CXR signs of reactivated TB?

A

patchy or nodular consolidation with cavitation typically in the upper zones, disseminates

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14
Q

What are the CXR signs of miliary TB?

A

‘millet seeds’ distributed uniformly throughout the lung fields

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15
Q

What are the 4 drugs used to treat acute pulmonary TB?

A

R - rimfampicin (6mo)
I - isoniazid (6mo)
P - pyrazinamide(2mo)
E- ethambutol (2mo)

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16
Q

What is TLCO?

A

Total lung diffusion capacity for carbon monoxide - shows how much carbon monoxide is taken into body during inhalation/exhalation

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17
Q

What is the BCG vaccination?

A

intradermal infection of live attenuated Tb which offers protection against severe and complicated TB but is less effective at protecting against pulmonary TB (for patients at higher risk of contact with TB)

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18
Q

What is pneumonia?

A

infection of the lung tissue which causes inflammation of the lung tissue and sputum filing the airways and alveoli

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19
Q

What are the causes of pneumonia?

A

streptococcus pneumoniae (50%)
haemophilus influenzae (20%)
moraxella catarrhalis (in immunocompromised patients/pts with chronic disease)
pseudomonas aeruginosa (pts with CF or bronchiectasis)
staphylococcus aureus (pts with CF)

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20
Q

What are the risk factors for pneumonia?

A

Bronchiectasis
Asthma
Cystic fibrosis
COPD
Malnutrition
Diabetes
Heart failure
Sickle cell disease
Liver or kidney disease
Hospitalisation
Older age

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21
Q

What is pleuritic chest pain?

A

pain on deep inspiration (feels like sandpaper on lungs during breathing)

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22
Q

What is the definition of hospital acquired pneumonia?

A

pneumonia which develops more than 48hrs after hospital admission

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23
Q

What are the key presentations of pneumonia?

A

Shortness Of breath
Cough productive of sputum
Fever
Haemoptysis (coughing up blood)
Pleuritic chest pain (sharp chest pain worse on inspiration)
Delirium (acute confusion associated with infection)
Sepsis

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24
Q

What are the signs of pneumonia?

A

Tachypnoea
Tachycardia
Hypoxia
Hypotension
Fever
Confusion

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25
What are the characteristic chest signs of pneumonia?
Bronchial breath sounds = harsh breath sounds equally loud on expiration and inspiration caused by consolidation of the lung tissue around the airway Focal coarse crackles = air passing through sputum in the airways Dullness to percussion due to lung tissue collapse and/or consolidation
26
What are the investigations for pneumonia?
CURB 65, CXR, FBC, U+Es, CRP Sputum cultures, blood cultures, legionella and pneumococcal urinary antigens
27
What are the implications of CURB 65 scores 0-5?
0-1 = mild, only admit if social circumstances or single worrying feature 2 = moderate, admit to hospital 3-5 = severe, admit and monitor closely 4-5 = consider admission to critical care unit
28
What are the mortality percentages for CURB 65 scores?
0=0.7% 1=2.1% 3=9.2% 4-5=15-40%
29
What is the management for pneumonia?
Mild CAP = 5 day course of oral antibiotics (amoxicillin or macrolide) Moderate - severe CAP = 7-10 day course of dual antibiotics (amoxicillin and macrolide)
30
What are the potential complications of pneumonia?
sepsis, pleural effusion, empyema, lung abscess, bronchiectasis, death
31
What is CURB-65?
An algorithm for assessment of pneumonia severity C - confusion (new disorientation in person, place or time) U - urea >7 R - respiratory rate ≥ 30 B - blood pressure <90 systolic or ≤ 60 diastolic 65 - age ≥ 65
32
What is cystic fibrosis?
autosomal recessive genetic condition affecting mucus glands which has multi-systemic effects
33
What is the prevalence of CF in children?
1 in 2500
34
What is the aetiology of CF?
Caused by a mutation of the CF transmembrane conductance regulatory gene on chromosome 7 (CFTR) There are many variants of this mutation, the most common being delta-F508 mutation which codes for cellular channels, particularly a type of chloride channel
35
What are the risk factors for CF?
FHx Caucasians
36
What are is the pathophysiology of CF?
Thick pancreatic and biliary secretion which cause blockage of the ducts, resulting in a lack of digestive enzymes such as pancreatic lipase in the digestive tract Low volume thick airway secretions that reduce airway clearance, resulting in bacterial colonisation and susceptibility to airway infections Congenital bilateral absence of the vas deferens in males
37
What are the key presentations of CF?
Meconium ileus (seen in 20% of babies with CF) Recurrent lower respiratory tract infections Failure to thrive (poor weight and height gain) Pancreatitis Chronic cough Thick sputum production Recurrent respiratory tract infections Loose, greasy stools (steatorrhoea) due to a lack of fat digesting lipase enzymes Abdo pain and bloating
38
What are the signs of CF?
Very salty sweat Nasal polyps Finger clubbing Crackles and wheezes on auscultation Abdominal distension
39
What are the investigations for CF?
Newborn blood spot testing GS: Sweat test (pilocarpine patch and electrodes used to test chloride concentration) - >60mmol/L = CF Genetic testing CFTR gene can be performed during pregnancy by amniocentesis or chorionic villous sampling
40
What is the management for CF?
Chest physiotherapy (multiple times daily) Exercise → improved resp function + reserve, helps clear sputum High caloric diet CREON tablets to digest fats in patients with pancreatic insufficiency Prophylactic flucloxacillin Treat chest infections Bronchodilators (salbutamol inhalers) Nebulised DNase (enzyme which breaks down DNA material in secretions → easier to clear) Nebulised hypertonic saline Vaccinations for pneumcoccal, influenza, varicella Lung transplant in ESRespF Liver transplant in liver failure Fertility treatment involving testicular sperm extraction for infertile males
41
What are some common infections in CF patients?
S. aureus H. influenzae P. aeruginosa
42
What are the complications of CF?
90% CF patients develop pancreatic insufficiency 50% develop diabetes 30% develop liver disease Most males are infertile due to absent vas deferens
43
What is bronchiectasis
permanent dilation of bronchioles (+ excessive mucus in them)
44
What are the causes of bronchiectasis?
Recurrent pulmonary infection leads to progressive bronchial damage Post infectious (18% of adult patients) COPD (15% of adult patients) Asthma (7%) Connective tissue disorders (9%) Allergic bronchopulmonary aspergillosis (5%) Immunodeficiency (5%) Aspiration or inhalation injury (4%) Genetic IBD Focal bronchial obstruction Idiopathic (29%) Other (e.g. Marfan, Ehlers-Danlos…)
45
What are the risk factors for bronchiectasis?
Post infection (e.g. TB, pneumonia) CF HIV ABPA (allergic bronchopulmonary aspergillosis - fungal infection of lung) Congenital airway disorders
46
What is the pathophysiology of bronchiectasis ?
Irreversible dilation, loss of cilia + mucus hypersecretion ↑risk of infection (as ↓mucociliary clearance)
47
What are the key presentations of bronchiectasis?
Productive cough with lots of sputum + dyspnoea Fever Fatigue Haemoptysis Wheezing
48
What are the signs of bronchiectasis on auscultation?
Crackles, high pitched inspiratory squeaks and rhonchi (low pitched wheezes)
49
What is the management for bronchiectasis?
Non-curative conservative : chest physio (+stop smoking) Drug: bronchodilators Consider abx if infection
50
What is pleural effusion?
Collection of fluid in the pleural cavity which can be exudative (high protein count >35g/L) Or transudative (lower protein count <35g/L)
51
What are the exudative causes of pleural effusion?
Exudative causes are related to inflammation which leads to protein leakage out of tissue into the pleural space: Lung cancer Pneumonia Rheumatoid arthritis Tuberculosis
52
WHat are the transudative causes of pleural effusion?
Transudative causes relate to fluid moving across into the pleural space: Congestive cardiac failure Hypoalbuminemia Hypothyroidism Meigs syndrome
53
What are the key presentations of pleural effusion
SOB Dullness to percussion over the effusion Reduced breath sounds Tracheal deviation away from the effusion if it’s massive
54
What are the signs of pleural effusion?
Reduced chest wall expansion Quiet breath sounds Stony dull percussion Reduced tactile/vocal fremitus Mediastinal shift away from affected side
55
WHat are the investigations for pleural effusion?
CXR (blunting of costophrenic angle, fluid in the lung fissures, larger effusions have a meniscus, tracheal and mediastinal deviation) Thoracocentesis (sample of pleural fluid, pH, lactate, WCC, microscopy, transudate or exudate)
56
What are the signs seen on CXR in pleural effusion?
Blunting of costophrenic angle Fluid in the lung fissures Larger effusions have a meniscus Tracheal and mediastinal deviation
57
What is Light's criteria?
measurements of a number of factors including protein used to show whether pleural effusion is transudative or exudative)
58
What are the different appearances of fluid aspirate taken from lungs in pleural effusion and what do they indicate?
Straw coloured/clear - transudate/exudate turbid /foul smelling - empyema/parapneumonic effusion Milky - chylothorax Blood stained - trauma/cancer/PE Food particles - esophageal rupture
59
What is the management for pleural effusion?
Conservative ; small effusions will resolve with treatment of the underlying cause Pleural aspiration (needle into lungs to remove fluid) Chest drain (drain the effusion, prevents recurrence)
60
What is empyema?
infected pleural effusion - suspected when the patient has improving pneumonia but new or ongoing fever - plueral effusion shows pus, acidic pH, low glucose and high LDL
61
What is the treatment for empyema?
chest drain to remove pus 6 weeks antibiotics
62
What is the treatment for malignant effusions?
depends on symptoms, treatment for underlying cancer and prognosis drain + pleurodesis --> chest drain (talc via drain), thoracoscopy (spray talc) if recurrent and problematic --> indwelling pleural catheter
63
WHat is haemothorax?
blood in pleural cavity
64
What are the causes of haemothorax?
trauma, post-operative, bleeding disorders, lung cancer, PE, aortic rupture, thoracic endometriosis
65
What is the management for haemothorax?
large bore chest drain, possible vascular intervention, surgical opinion
66
What is hydropneumothorax?
air and fluid in pleural space
67
WHat are the causes of hydropneumothorax?
iatrogenic, gas forming organisms, thoracic trauma
68
What is pneumomediastinum?
where air from the lungs/trachea/oesophagus escapes into neck/face and abdomen
69
What causes pneumomediastinum?
surgical emphysema/pneumothorax oesophageal rupture (Boerhaave's syndrome)
70
What are the causes of pleural thickening?
related to asbestos exposure following infection/empyema/chest trauma/haemothorax cancer (consider if nodular /1 cm depth)
71
What is pneumothorax?
excess air accumulation in the pleural space, causing ipsilateral collapse
72
What is the aetiology of pneumothorax?
Can be primary (spontaneous (rupture of apical pleural bleb), no underlying cause) or secondary (to trauma or pathology) Secondary pathological causes: Known lung disease -60% COPD -Asthma/ILD/CF/Lung cancer -Cystic lung disease Infection -PCP/TB -lung abscess Genetic predisposition -Marfan’s syndrome, Birt-Hogg Dube -LAM - Lymphangioleiomyomatosis Catamenial Pneumothorax Traumatic causes: Penetrating chest wall injury Puncture from rib Rupture bronchus/oesophagus
73
What are the risk factors for primary spontaneous pneumothorax?
male, smokers, tall, age 20-40yrs, previous occurrence
74
What is the pathophysiology of pneumothorax?
Pleural space is normally a vacuum (no air) Breach in pleura (trauma/CT disorders) e.g. subpleural bullae burst –> fistula between pleural space + airways → air in the pleural space THis causes intrapleural pressure to be negative which leads to air being sucked into cavity leading to partial or total lung collapse
75
What are the key presentations in pneumothorax?
SOB One sided sharp pleuritic chest pain Decreased breath sounds Hyperresonant percussion ipsilaterally (increased air) Can be asymptomatic
76
What are the signs of pneumothorax?
Often no clinical signs except in severe cases Tachypnoea Hypoxia Unilateral chest wall expansion Reduced breath sounds Hyper-resonant percussion note Red flags (tension pneumothorax) Deviated trachea Surgical emphysema Distended neck veins Cardiovascular compromise
77
WHat are is the management for pneumothorax?
Small = self-resolving Larger - needle decompression (remove air with syringe), chest drain Surgical (if recurrent) - pleurodesis (insertion of a mildly irritant drug into pleural space to close space and prevent further collection of air or fluid)
78
What is tension pneumothorax?
air can flow into pleural space but can't leave --> intrapleural pressure increases with every breath (can even press on heart --> cardiac disorder symptoms)
79
What are the signs of a tension pneumothorax?
tracheal deviation away from side of pneumothorax, reduced air entry to affected side increased resonance to percussion on affected side, tachycardia, hypotension
80
What is the treatment for tension pneumothorax?
insert large bore cannula into 2nd intercostal space at the midclavicular line, needle decompress and then chest drain
81
What forms the triangle of safety for chest drains?
The 5th intercostal space (inferior nipple line) Mid-axillary line (or the lateral edge of the latissimus dorsi) Anterior axillary line (lateral edge of the pectoralis major)
82
What is pulmonary hypertension?
Resting mPAP >25mmHg measure with right heart catheterisation *often results in RHS heart failure; cor pulmonale
83
What are the causes of pulmonary hypertension?
Pre-capillary → pulmonary emboli, primary pulmonary hypertension Capillary + lung → COPD, asthma Post-capillary → LV failure Chronic hypoxemia → COPD, altitude
84
What is the pathophysiology of pulmonary hypertension?
Increasing the pressure and resistance in the pulmonary arteries causes strain on the right side of the heart trying to pump blood through the lungs which also causes a back pressure of blood into the systemic venous system → RVH + dilated pulmonary arteries
85
What are the key presentations of pulmonary hypertension?
SOB Syncope Tachycardia Raised JVP Hepatomegaly Peripheral oedema
86
WHat are the investigations for pulmonary hypertension?
ECG (RVH→ larger R waves (V1-V3) and S waves (V4-V6), right axis deviation, RBBB) GS: CXR (dilated pulmonary arteries, RVH) NT-proBNP blood test (raised) Echo
87
What is the management for pulmonary hypertension?
Primary: IV prostanoids (e.g. epoprostenol) Endothelin receptor antagonists (e.g. macitentan) Phosphdiesterase-5 inhibitors (e.g. sildenafil) Secondary: Treat underlying cause Supportive treatment for complications e.g. resp failure, arrhythmias and heart failure
88
What is the prognosis for pulmonary hypertension"
30-40% 5yr survival rate
89
What is pulmonary fibrosis?
thickening or scarring of the lung tissue, the most common interstitial lung disease
90
What are the risk factors for pulmonary fibrosis?
Smoking Occupational (e.g. dust) Drugs (methotrexate) Viruses (EBV, CMV)
91
What are the key presentations of pulmonary fibrosis?
Exertional dyspnoea Dry unproductive cough
92
What are the investigations for pulmonary fibrosis?
Spirometry = restriction (FEV1:FVC >0.7) but FVC ↓ (<0.8 normal) High res CT (chest) → ground glass lungs + traction bronchiectasis
93
What is the management for pulmonary fibrosis?
Smoking cessation + vaccines pirfenidone , nintedanib Surgery (lung transplant)
94
What is sarcoidosis?
Idiopathic granulomatous inflammatory disease
95
What are the risk factors for sarcoidosis?
Female 20-40yrs Afrocaribbean
96
What is the pathophysiology of sarcoidosis?
Granulomas are nodules of inflammation full of macrophages which can occur in almost any organ in the body (most commonly lungs) Symptoms vary dramatically from asymptomatic (up to 50%) to severe + life-threatening
97
What are the key presentations of sarcoidosis?
fever , fatigue Resp = dry cough; dyspnoea Other = eye lesions (uveitis), lupus pernio (blue + red nodules on nose + cheeks)
98
What is Lofgren's syndrome?
A specific presentation of sarcoidosis characterised by: Erythema nodosum, lymphadenopathy, polyarthralgia
99
What are the investigations for sarcoidosis?
CXR (staging 1-4) → bilateral hilar adenopathy + pulmonary infiltrates GS: Lung biopsy → non-caseating granuloma ↑Serum Ca2+, ↑serum ACE, hypercalcaemia
100
What are the differential diagnoses for sarcoidosis?
Tuberculosis, lymphoma, hypersensitivity pneumonitis, HIV, toxoplasmosis, histoplasmosis
101
What is the management for sarcoidosis?
Early stages are self-resolving Symptomatic patients → corticosteroids 2nd line options: methotrexate or azathioprine
102
What is the prognosis for sarcoidosis?
60% spontaneously resolve in 6 months, can progress with pulmonary fibrosis and pulmonary hypertension potentially requiring a lung transplant
103
WHat is hypersensitivity pneumonitis
Type III hypersensitivity reaction to an environmental allergen which causes parenchymal inflammation and destruction in people that are sensitive to that allergen
104
What are some examples of hypersensitivity pneumonitis
Bird fancier’s lung - caused by proteins in bird feathers or droppings Farmer’s lung - caused by mould which grows on hay, straw and grain Hot tub lung - caused by bacteria in water vapour from hot tubs Humidifier lung - caused by fungi and bacteria in humidifiers, heating and air con systems
105
What is the aetiology of hypersensitivity pneumonitis?
Over 300 known causes including: Bacteria Moulds and fungi Certain chemicals and metals Animal and plant proteins
106
What are the risk factors for hypersensitivity pneumonitis?
Occupation (e.g. farming), bird keeping 50-70 yrs
107
What are the key presentations of acute hypersensitivity pneumonitis?
SOB Dry cough Chest tightness Chills Fatigue Fever Muscle aches
108
What are the symptoms of chronic hypersensitivity pneumonitis?
SOB Cough Fatigue Weight loss Finger or toe clubbing
109
WHat are the investigations for hypersensitvity pneumonitis?
Bronchoscopy + broncheolar lavage (shows lymphocytes and mast cells) Allergy blood tests Imaging (CXR, CT) Lung function tests
110
What is the management for hypersensitivity pneumonitis?
Remove allergen, give oxygen and steroids Anti-fibrotic drugs (slow lung scarring) Oxygen therapy Pulmonary rehabilitation Lung transplant
111
What is pharyngitis?
Inflammation of the pharynx +/- exudate
112
What is the aetiology of pharyngitis?
Viral (EBV, adenoviruses) - 70-80% Bacterial (group A B-haemolytic strep (GAS); S. pyogenes) Fungal
113
What are the key presentations of pharyngitis?
Sore throat Fever Viral = + cough + nasal congestion Bacterial = + exudate headache
114
What are the investigations for pharyngitis?
Rapid antigen test for group A strep Nucleic acid amplification for group A strep
115
What is the management for pharyngitis?
generally self-limiting analgesia OTC medications antibiotics for bacterial
116
What is sinusitis? and what are the 4 types
Inflamed mucosa of nasal cavity and nasal sinuses Acute ≤4 weeks Subacute 4-12 weeks Chronic ≥12 weeks Recurrent acute ≥4 episodes per year
117
What is the aetiology of sinusitis?
Mostly viral (<10 days, non purulent discharge) Sometime bacterial - S.pneumococcus (40%), H. influenzae (30%)
118
What are the risk factors for sinusitis?
viral URTI allergic rhinitis
119
WHat is the pathophysiology of sinusitis?
Most likely to be caused by the interaction of a predisposing condition (e.g. environmental triggers), a viral infection, and a consequent inflammatory response with the sinonasal mucosa With increased oedema and mucus production, the sinus ostium is obstructed, blocking normal ventilation and drainage of the sinus. With decreased mucociliary clearance, stasis of secretions occurs and a secondary bacterial infection can take place
120
What are the key presentations of sinusitis?
Purulent nasal discharge Nasal obstruction Facial pain/pressure
121
What are some other symptoms of sinusitis?
Cough Myalgia Sore throat Hyposmia Oedematous turbinate Fever
122
What is the management for sinusitis?
Generally self-limiting Treatment is primarily symptomatic
123
What is otitis media?
Infection involving the middle ear space which is a common complication of viral respiratory illnesses
124
What are the risk factors for otitis media?
Young age FHx Native american or native alaskan Lower socioeconomic status Craniofacial anomaly Immunological deficiency
125
What is the pathophysiology of otitis media?
Upper respiratory viruses can infect the nasal passages, eustachian tube and middle ear, causing inflammation and impairing the mucociliary action and ventilatory function of the eustachian tube → development of OM Middle ear effusion develops and nasopharyngeal bacteria contaminate the effusion Suppuration and subsequent pressure against the tympanic membrane lead to pain and fever, which are typical symptoms of OM
126
What are the key presentations of OM
Otalgia (ear pain) Preceding upper resp symptoms Bulging tympanic membrane Myringitis
127
What are some other symptoms of OM?
Irritability Sleep disturbance Fever Decreased appetite
128
What is the management of OM?
Analgesia Some patients may require antibiotic therapy
129
What is acute epiglottitis?
Infection of the supraglottis which can result in airway compromise
130
What is the aetiology of acute epiglottitis?
infection of the supraglottis which can result in airway compromise
131
What are the causes of epiglottitis>
Most common: H.influenzae Also Strep penumoniae, S. aureus, MRSA
132
What is the pathophysiology of acute epiglottitis?
Inflammatory pathways lead to localised oedema of the airway, exponentially increasing airway resistance while narrowing the effective supraglottic aperture The glottis is usually not inflamed or affected as the process affects the supraglottic structures
133
What are the key presentations of acute epiglottitis?
tripoding (leant forard, mouth open + tongue out = max air in) sore throat SOB dysphagia acute distress fever
134
What are the investigations for acute epiglottitis?
GS: Laryngoscopy Lateral XR radiograph (thumbprint sign), FBC, cultures of blood/supraglottis
135
What is the management for acute epiglottitis?
ABC - secure airway Oxygen Intravenous antibiotics Corticosteroids if needed
136
What is croup?
Complication of upper respiratory tract infection characterised by sudden onset barking cough
137
What is the aetiology of croup?
Due to viral infection Often accompanies parainfluenza/measles infection
138
What are the risk factors for croup?
Children 6 months-6years Male Prior intubation
139
What is the pathophysiology of croup?
Symptoms result from upper-airway obstruction due to generalised inflammation and oedema of the airways. At the cellular level this progresses to necrosis and shedding of the epithelium Narrowed subglottic region is responsible for the symptoms of seal-like barky cough, stridor (from increased airflow turbulence), and sternal/intercostal indrawing If the upper airway obstruction worsens, respiratory failure can result, leading to asynchronous chest and abdominal wall motion, fatigue, hypoxia, and hypercapnia
140
What are the key presentations of croup?
Hoarse voice Barking cough Stridor Abrupt onset of symptoms Respiratory distress Fatigue Signs of hypoxia/hypercapnia in severe cases
141
What is the management for croup?
Single dose of dexamethasone Supportive care
142
What is whooping cough?
Chronic cough caused by Bordetella pertussis (gram -ve bacillus)
143
What are the risk factors for whooping cough?
unvaccinated/under-vaccinated <5y/o close contact with infected person
144
What is the pathophysiology of whooping cough?
bordatella ↑↑virulence - haemaglutinin + fimbriae adhere to URT - adenylate cyclase toxin inhibits phagocyte chemotaxis - pertussis toxin inhibits alveolar macrphages
145
What are the key presentations of whooping cough?
Pertussis typically starts with mild coryzal symptoms (low grade fever and mild, dry cough) Paroxysmal cough starts after a week + (sudden and recurring attacks of coughing) Loud inspiratory whooping sound between coughs (forceful sucking in of air) Patient can cough so hard they faint, vomit or even develop pneumothorax Can present with apnoeas rather than cough
146
What are the investigations for whooping cough?
Nasopharyngeal or nasal swab with PCR testing or bacterial culture can confirm the diagnosis within 2 to 3 weeks of symptom onset If cough present for 2+ weeks - anti-pertussis toxin immunoglobulin G
147
What is the management for whooping cough?
supportive care macrolide antibiotics (azithromycin, erythromycin, clarithromycin)
148
What are the primary metastasis sites of lung cancer?
bone, liver, adrenals, brain, lymph nodes
149
What are the types of non-small cell cancer affecting the lung parenchyma?
squamous, adenocarcinoma, carcinoid, large cell
150
What is mesothelioma?
malignancy affecting the mesothelial cells of the pleura which is strongly linked to asbestos inhalation
151
What are the risk factors for mesothelioma?
male 50-80 yrs asbestos exposure radiation exposure genetic predisposition
152
What is the pathophysiology of mesothelioma?
Suggested that exposure to asbestos fibres results in recruitment and activation of alveolar macrophage and neutrophils with subsequent generation of reactive oxygen and nitrogen species Chronic inflammation and oxidative stress may culminate in DNA damage alterations in gene expression, and eventually malignant transformation
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What are the key presentations of mesothelioma?
Cancer symptoms: weight loss, night pain, fatigue SOB Cough Pleuritic chest pain Haemoptysis Finger clubbing Recurrent pneumonia Lymphadenopathy
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What are the investigations for mesothelioma?
CXR + CT (pleural thickening), CA-125 (non-specifically raised in many tumours, sensitive but not specific) GS: lung biopsy
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What is the management for mesothelioma?
Very aggressive tumour so tx normally palliative If found early can try surgery + chemotherapy (but generally resistant)
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What occurs in restrictive lung diseases?
Expansion of the lung is reduced due to: 1. altered lung parenchyma 2. pleural disease 3. neuromuscular disease 4. chest wall disease
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What are the common obstructive ventilatory disorders or "airways diseases"?
COPD Asthma Bronchiectasis Cystic fibrosis
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What is dyspnoea?
shortness of breath or breathlessness
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What is the MRC dyspnoea scale?
Assessment tool for degree of baseline functional disability due to dyspnoea
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What are the categories in the MRC dyspnoea scale?
0 - no breathlessness except with strenuous exercise 1 - shortness of breath when hurrying on the level or walking up a slight hill 2 - walks slower than people of the same age on the level because of breathlessness or has to stop for breath when walking at own pace on the level 3 - stops for breath after walking about 100m or after few minutes on the level 4 - too breathless to leave the house or breathless when dressing or undressing
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What are the common causes of dyspnoea?
asthma heart failure myocardial ischaemia COPD interstitial lung disease pneumonia psychogenic disorders
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What is type 1 respiratory failure?
associated with damage to lung tissue which prevents adequate oxygenation of the blood (hypoxaemia) but the remaining normal lung is still sufficient to excrete CO2. => low O2, normal or low CO2, PaO2 <8kPa (low) and normal or low PaCO2
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WHat is type 2 respiratory failure?
when alveolar ventilation is insufficient to excrete the CO2 being produced. Inadequate ventilation is due to reduced ventilatory effort or inability to overcome increased resistance to ventilation. It affects the lung as a whole and therefore CO2 accumulates => low or normal PaO2 and PaCO2 >6.0kPa (hypercapnia)
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What are the signs and symptoms specific to type 1 respiratory failure (hypoxaemia)?
dyspnoea, irritability confusion, somnolence, fits tachycardia, arrythmia tachypnoea cyanosis
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What are the signs and symptoms specific to type 2 respiratory failure?
headache change of behaviour coma papilloedema warm extremities
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Which respiratory conditions cause T1 respiratory failure?
pulmonary oedema pneumonia COPD asthma acute respiratory distress syndrome chronic pulmonary fibrosis pneumothorax pulmonary embolism pulmonary hypertension
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Which conditions cause T2 respiratory failure
COPD (mc) chest-wall deformities, respiratory muscle weakness CNS depression severe asthma myasthenia gravis muscle disorders obesity hypothyroidism adult respiratory syndrome
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What is COPD?
Chronic obstructive pulmonary disease = progressively worsening, irreversible airflow limitation
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What are the types of COPD?
chronic bronchitis emphysema A1AT deficiency
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What are the causes of COPD?
almost always due to smoking patients are susceptible to exacerbations during which there is worsening of their lung function exacerbations are often triggered by infections
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What are the risk factors for COPD?
SMOKING air pollution genetics occupational exposure age
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What is the pathophysiology of chronic bronchitis?
1. hypertrophy and hyperplasia of mucous glands in response to toxic or infectious stimuli 2. chronic inflammation cells infiltrate bronchi + bronchioles --> luminal narrowing 3. mucous hypersecretion, ciliary dysfunction, narrowed lumen --> infection risk + airway trapping
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What is the pathophysiology of emphysema?
1. destruction of the elastin layer in alveolar ducts/sacs/respiratory bronchioles 2. elastin keeps the walls open during expiration (Bemouli principle) 3. decreased elastin --> air trapping distal to blockage
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What are the different types of emphysema?
centriacinar (respiratory bronchioles affected only) panacinar (rib, alveoli, alveolar sacs) distal acinar irregular
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What is the pathophysiology of A1AT deficiency COPD?
Autosomal dominant inheritance - A1AT normally degrades neutrophil elastase (NE) and protects excess damage to elastin layer in lungs especially - deficiency results in increased NE which causes panacinar emphysema and liver issues
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What are the clinical manifestations of COPD?
Chronic cough with often purulent sputum (infection risk due to mucus hypersecretion + stasis) Blue bloater (chronic bronchitis) - chronic purulent cough, dyspnoea, cyanosis, obesity Pink puffer (emphysema) - mimics cough, pursed lip breathing, cachectic (muscle wasting), barrel chest, hyperresonant, percussion Most patients a mix of BB/PP
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What are the investigations for COPD?
clinical exam/history GS: spirometry (FEV1/FVC ratio <0.7) reversibility testing with B-2 agonists like salbutamol during spirometry testing, CXR, FBC sputum, ECG/echo, serum A1AT
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What are the differential diagnoses for COPD?
lung cancer, fibrosis, heart failure, asthma
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What is the management for COPD
first smoking cessation + vaccines for flu + pneumococcal 1. short acting bronchodilators - B-2 agonists (SABA) (salbutamol/terbutaline) or short acting antimuscarinics (ipatropium bromide) 2. Long acting beta agonist (LABA) + long acting muscarinic antagonist (LAMA) for more severe cases: + nebulisers, oral theophylline, oral mucolytic therapy + long term oxygen therapy is used for severe COPD
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What is asthma?
chronic reversible airway disease characterised by airway obstruction, airway hyperresponsiveness, inflamed bronchioles +mucous hypersecretion
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What are the types of asthma and their causes?
allergic (70%) - IgE mediated, extrinsic, T1 hypersensitivity - triggered by pollen, smoke dust, mould, antigens non-allergic (30%) - non-IgE mediated, intrinsic - may present later, harder to treat, associated with smoking (like COPD)
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What are the risk factors for asthma?
Family History allergies atopic dermatitis hay fever obesity smoking occupational exposure nasal polyps, aspirin sensitivity (+ asthma = Samter's triad)
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What is the pathophysiology of asthma?
TH2 cells are overexpressed in airways and when exposed to trigger release cytokines (IL-3,4,5,13), produce IgE antibodies and recruit eosinophils IgE stimulates mast cell degranulation which leads to histamine, leukotriene and tryptase release eosinophilia leads to release of toxic proteins this causes bronchoconstriction, mucous hypersecretion
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What are the key presentations of asthma?
Wheeze, cough (typically dry), chest tightness, SOB *typically episodic with triggers and diurnal variation * episodes can be classed as moderate (PEF 50-75%), severe (PEF 33-50% - can't finish sentences), life threatening (PEF <33% - decreased consciousness, fatal (hypercapnic pKa>6)
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What are the investigations for asthma?
Spirometry - ↑FeNO + spirometry showing obstruction (FEV1/FVC<0.7), FEV1 >12%
186
What is the chronic asthma treatment algorithm
1. SABA 2. SABA + ICS 3. SABA + ICS + LTRA (leukotriene receptor antagonist like montelukast) 4. SABA + ICS + LABA +/- LTRA 5. Increases ICS dose
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What is the management for asthma exacerbations?
O2 Nebulisers SABA ICS hydrocortisone IV MgSO4 IV theophylline CPAP/BiPAP +/- Abx if infection present
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What are the 4 types of non-small cell lung cancers?
Adenocarcinoma (45% of NSCLC) Squamous cell carcinoma Carcinoid Tumour Large cell carcinoma
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What is adenocarcinoma?
Malignant tumour formed from the mucous-producing glandular epithelial cells lining the outside of the lungs - commonly caused by asbestos - mets common --> bone, brain, adrenals, lymph nodes, liver
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What is squamous cell carcinoma?
malignant tumour arising from lung epithelium which forms lesions with central necrosis and may secrete PTHrP--> hypercalcaemia - mostly smokers - late mets, mostly locally spread
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What are carcinoid tumours?
serotonin-secreting neuroendocrine tumours which mostly arise in the GIT and sometimes the lungs - associated with genetics, MEN1 mutations and neurofibromatosis
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What is large cell carcinoma?
lung cancer in which the cells are large and look abnormal when viewed under microscope - fast growing, aggressive type of cancer
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What are the risk factors for NSCLC?
Smoking Asbestos Coal Ionising radiation Lung disease already present COPD Older age
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What are the key presentations of NSCLC?
Chest pain (+/- shoulder pain) Cough + haemoptysis Cancer symptoms; weight loss, nausea, fatigue Signs of mets (e.g. hoarse voice Permberton sign, Homer’s syndrome)
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What are the investigations for NSCLC?
Imaging - CXR, CT GS: Bronchoscopy + biopsy MRI - staging (TNM)
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What is the management for NSCLC?
If caught early ⇒ surgical excision Metastasised ⇒ chemo +/- radio e.g. mAB therapy cetuximab
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WHat is small cell carcinoma?
Malignant epithelial tumour arising from cells lining the lower respiratory tract
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What are the risk factors for SCC?
Cigarette smoking Environmental tobacco exposure Radon gas exposure Asbestos exposure Aged 65 to 70 Male
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What is the appearance of SCC on microscopy?
The tumour cells and small and densely packed, with scant cytoplasm, finely granular nuclear chromatin, and absence of nucleoli
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What are the key presentations of SCC?
Cough Dyspnoea Haemoptysis Chest pain Weight loss Fatigue Hoarseness Nausea
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What are the investigations for SCC?
CXR, CT Bronchoscopy and biopsy MRI - staging (TNM)
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What is the management for SCC?
Most patients present with advanced disease so surgery usually not an option 1st line: chemotherapy +/- radio (often unsuccessful) Metastasised ⇒ palliative
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What are the indicators of severity in respiratory infections?
pro-inflammatory cytokines vasodilation impaired cardiac contractility reduced blood pressure impaired organ perfusion tissue hypoxaemia
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What are the signs of sepsis?
delerium renal impairment - raised urea increased oxygen demand - high resp rate lactic acid production from anaerobic respiration systolic diastolic BP drop
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Why is the respiratory tract so susceptible to infection?
in the lungs a very thin membrane for gas transfer is needed which also means there is not much space for barriers, immune defence or commensals like in other parts of the body.