Respiratory Flashcards
Inspiration
Downward contraction of diaphragm
Upward and Outward movement of the ribs due to contraction of external intercostal muscle
Expiration
Is passive driven by elastic recoil of the lungs
What is the gas exchange unit of the lung
Acinus
Acinus composed of
Barnching respiratory bronchioles and clusters of alveoli
Most smallest area in the respiratory tract
Glottis and trachea
Type 1 pneumocyte
√ Flattened epithelial cells
√ Lining of alveoli
Type 2 Pneumocytes
√ Fewer than type 1
√ Produce surfactant
√ Can divide to reconstitute type 1 pneumocyte after lung injury
Surfactant
√ Mixture of phospholipid
√ Reduce surface tension
√ Counteract the tendency of the alveoli to collaps
How maximum respiratory volume is limited by lung
Elastin fibers allow the lung to be easily distended at physiological lung volume. But collagen fibres cause increasing stiffness as full inflation is approached
Small airway patency is maintained by
Elastin fibre in alveolar wall by radial traction on the airway walls
Calculation of alveolar ventilation
AV= (tidal volume - dead space) × Respiratory rate
Gas exchange occurs by
Alveoli which are connected to each other
by the pores of kohn
Acinus
The unit of lung supplied by a terminal bronchiole
Pulmonary artery
Bronchial artery
PA carries desaturated blood
BA Systemic supply to airway tissue
What is the origin of the respiratory cycle
Respiratory neuron in the posterior medulla oblongata
Control of breathing modulated by
√ Central chemoreceptor in the ventrolateral medulla senses pH in the CSF and stimulated indirectly by a rise in the arterial Pco2
√ Carotid bodies sense hypoxemia mainly activated by arterial Po2 value less than 8kpa (60mmHg)
√ Muscle spindles in respiratory muscle
√ Vagal sensory fibres in the lung stimulated by stretch, inhaled toxins, disease process in interstitium
√ Cortical (Volitional) and limbic ( Emotional) influences
Disease occurring due to defective mucociiary transport
√ Cystic fibrosis
√ Primary ciliary dyskinesia
√ Young syndrome
Which are characterised by repeated sino-pulmonary infections and bronchietesis
Airway secretions contains
√ Antimicrobials peptides such as defensins and lysozyme
√ IgA
√ Antiproteinase
√ Anti oxidant
Premature emphysema associated with which deficiency
alpha 1 antitrypsin which regulates neutrophil elastase
What is the investigation of choice for pulmonary thromboembolism
CT Pulmonary Angiography (CTPA)
Indication of High CT
- Diffuse Parenchymal Lung Disease
- Identifying airway thickening
- Bronchiectasis
- Emphysema
FDG PET indication
✓ Staging of mediastinal lymph nodes & distal metastatic disease in lung cancer
✓ Investigation of pulmonary nodules
✓ Differentiate benign from malignant pleural disease
✓ Extent of extrapulmonary disease in sarcoidosis
Causes of consolidation on CXR
Inflammation
Infection
Infarction
Bronchoalveolar cell carcinoma
Causes of Multiple Nodule on CXR
Miliary Tuberculosis
Dust inhalation
Metastatic malignancy
Healed Vericella Pneumonia
Rheumatoid arthritis
Causes of Cavitating lesion on CXR
Tumor
Abscess
Infarct
Pneumonia( staphylococci/ klebsiella)
GPA
Causes of increased translucency On CXR
Bullae
Pneumothorax
Oligaemia
Causes of hilar lymph node enlargement
Unilateral: TB, Lymphoma, Lung cancer
Bilateral: TB, Lymphoma, Sarcoidosis, Silicosis
What is the point of care investigation in assessing Pleural Space
Transthoracic Ultrasound
Transbronchial biopsy ( Taken Using Bronchoscopy) Is the gold standard investigation for
Sarcoidosis and Diffuse Malignancy
Rigid Bronchoscopy is used in
Massive Haemoptysis
Removal of foreign body
𝗧𝗛𝗢𝗥𝗔𝗖𝗢𝗦𝗖𝗢𝗣𝗬 (Pleuroscopy) is 𝗚𝗼𝗹𝗱 𝘀𝘁𝗮𝗻𝗱𝗮𝗿𝗱 𝗳𝗼𝗿
+ Evaluation of pleural surfaces
+ Characterisation of complex pleural effusion
+ Identification of exudate & haemorrhage
+ Analysis of superior sulcus (apical) tumors
What is the first line diagnostic test for respiratory viruses ( influenza, SARS COV-2) and Bacterial Pathogens ( Legionella, Mycoplasma )
NAAT ( Nucleic acid amplification Test)
FEV1/FVC less than 70% indicate
Airflow obstruction
Lung volume is measured by
Body Plethysmography
Dry cough + Inspiratory Crackles suggestive of
Interstitial lung disease
Non-respiratory causes of dyspnoea
CVS Causes- Pulmonary Oedema
Heart Failure
MI
Others:
Metabolic acidosis
Salicylates overdose
Ethylene glycol Poisoning
Severe Anaemia
Obesity
Deconditioning
Respiratory causes of finger clubbing?
- Pulmonary TB
- Bronchiectasis
- Lung Abscess
- Empyema
- Cystic fibrosis
- Pulmonary fibrosis
- Lung Cancer
- Mesothelioma
- Fibroma
Non-respiratory causes of clubbing
Cyanotic Heart Disease
Infective endocarditis
Arteriovenous Shunt
IBD
Liver Cirrhosis
Coeliac Disease
Thyrotoxicosis
Primary Hypertrophic Osteoarthropathy
Common Causes of Hemoptysis?
- Lung cancer
- Bronchiectasis
- Acute Bronchitis
- Pulmonary TB
- Pulmonary infarction
- Acute LVF
Causes of catastrophic bronchial Haemorrhage/ Haemoptysis ?
Lung abscess
Bronchiectasis
Intracavitary Mycetoma
CVS causes of haemoptysis
Acute LVF
Mitral Stenosis
Aortic aneurysm
High metabolic activity of nodules in PET CT suggestive of ?
Malignancy
Risk of malignancy in pulmonary nodule
✓ Age > 40 yr
✓ H/O smoking
✓ Exposure to asbestos, silica, uranium & radon
✓ H/O lung cancer in a first-degree relative
✓ Size > 3 cm
✓ Spiculated margin
✓ Location in upper lobes
Causes of pleural effusion
- Pneumonia
- TB
- Malignancy
- Pulmonary infarction
- HF
- Sub diaphragmatic disorder (subphrenic abscess, pancreatitis)
- Hypoproteinaemia (Nephrotic syndrome, Liver failure, Malnutrition)
- CTD ( SLE, RA)
- Myxoedema
- Uremia
Features Suggestive empyema in pleural effusion
Fluid Is thick and Turbid
Fluid glucose of < 3.3 mmol/L
LDH > 1000 IU/L
PH< 7
Causes of Type I respiratory failure
Acute asthma
ARDS
Pneumonia
Pneumothorax
Pulmonary Oedema
Pulmonary Embolism
Lobar Collapse
Chronic:
COPD
Lung Fibrosis
Lymphangitic carcinomatosis
Right to left shunt
Causes of type II respiratory failure
Acute Exacerbation of COPD
Acute Severe asthma
Upper airway Obstruction
Narcotic drugs
Acute neuropathies / Paralysis
Flail Chest Injury
COPD
Sleep Apnoea
Kyphoscoliosis
Myopathies/ Muscular dystrophy
Ankylosing Spondylitis
What is the respiratory stimulant drug?
Doxapram
Indication for single lung transplantation
Advanced emphysema
Lung fibrosis
Contraindication for single lung transplantation
Chronic bilateral Pulmonary infection
Such as : Bronchiectasis, cystic fibrosis
Bilateral lung transplantation is standard
Combined hurt lung transplantation is indicated in
Advanced congenital heart disease (Eisenmenger syndrome)
Primary Pulmonary hypertension not responsive to medicine
Which drug is used to prevent chronic lung allograft dysfunction (CLAD)
Ciclosporin
Mycophenolate
Tacrolimus
Feature of CO2 retention
Warm periphery
Bounding pulse
Flapping tremor
Delirium
Morning headache
Which drugs trigger asthma?
Beta blockers
Aspirin
NSAIDS
OCP
Cholinergic Agent
Prostaglandin F2@
Betel nuts
Dx criteria of asthma
Mostly clinical
Clinical history plus either or
• FEV1 = Or > 12% (and 200ml) increase following administration of bronchodilator / trial of Glucocorticoid. Greater confidence is gained if the increase is >15% and >400 ml
• > 20% diurnal variation on 3 days or more in a week for 2 weeks on PEF diary
• FEV1 15% or more decrease following 6 min of exercise
Features of acute severe asthma
★ PEF 33 - 50% predicted (<200L/min)
★ Heart rate >110 bpm
★ Respiratory Rate > 25 breaths/ min
★ Inability to complete sentence in one breath
Features of life threatening asthma
★ PEF <33% predicted
★ SpO2 < 92% or PaO2 < 8kpa
★ Normal or raised PaCO2
★ Feeble respiratory effort
★ Silent chest
★ Cyanosis
★ Bradycardia or Arrhythmia
★ Hypotension
★ Exhaustion
★ Delirium
★ Coma
Indication for assisted ventilation in acute severe asthma
★ Coma
★ Respiratory Arrest
★ Deterioration of ABG despite optimal therapy
- PaO2 < 8kpa and falling
- PaCO2 > 6Kpa and Rising
- pH low and falling
★ Delirium, Drowsiness, Exhaustion
Extrapulmonary effect of COPD
★ Osteoporosis
★ Skeletal muscle dysfunction
★ Weight loss
★ Peripheral Oedema
★ Increased circulating inflammatory markers
Younger pt with predominantly basal emphysema
Should asses a1 antitrypsin
What is the central to the mx of breathlessness?
Bronchodilator therapy
Prognosis of COPD
• It is inversely related to age and directly related to post bronchodilator FEV1
• Additional poor prognostic factors include
- Weight loss
- Pulmonary hypertension
•Scoring for prognosis done by BODE index
Where -
★ Body mass index
★ Airflow obstruction expressed as FEV1
★ Dyspnoea according mMRA scale
★ Exercise
• Highest bode index is 10 a score between 7-10 predict 82% mortality at 4 years
Most common cause of bronchiectasis
TB
Bronchiectasis + sinusitis+ transposition of viscera
Kartagener syndrome
Recurrent Bronchiectasis + Malabsorption +DM+ Infertility
Cystic fibrosis
Bronchiectasis + Asthma
Allergic bronchopulmonary aspergillosis
Chronic cough with copious sputum with coarse crakles with or without haemoptysis
Bronchiectasis
Rx of bronchiectasis
Regular daily physiotherapy
CT Scan findings of bronchiectasis
Thickening of bronchial wall
Extensive dilation of bronchi
Ring shadows
Most men with CF are infertile due to?
Failure to development of vas deferens
Respiratory features and complications in CF
- Progressive airway obstruction
- Infective exacerbation of bronchiectasis
- Respiratory failure
- Spontaneous Pneumothorax
- Allergic bronchopulmonary aspergillosis
- Lobar collapse due to secretion
- Haemoptysis
- Pulmonary hypertension
- Nasal polyp
Others defect of CF
Malabsorption and steatorrhea
Intestinal obstruction
Increased risk of malignancy
Gallstones
Diabetes
Infertility
Delayed puberty
Osteoporosis
Most common causes of lung infection in cystic fibrosis
Staph aureus ( child)
Others are-
P. Aeroginosa (adult)
Strentophomonas maltophila
Burkholderia capacia
Aspergillus fumigatus
Investigation and Rx for CF
Inv: sweat electrolyte testing and genotyping
Rx: chest physiotherapy
CFTR correctors: lumacaftor, ivacaftor
CFTR potentiators: elexacaftor, tezacaftor, ivacaftor
What is the most common URTI and causes of it?
Acute coryza caused by rhinovirus infection
Lobar pneumonia
Homogenous consolidation affecting one or more lung lobes
Associated with pleural inflammation
Bronchopneumonia
Patchy alveolar consolidation affecting both lower lobes
Associated with bronchial and bronchiolar inflammation
Virus causing pneumonia
• Influenza, parainfluenza
• Measles
• Varicella
• Herpes simplex
• CMV
• Adenovirus
• Coronaviruses
What is the most common infecting agent of CAP?
Strepto. Pneumoniae
Rust coloured sputum / herpes labialis with features of pneumonia caused by
Streptococcus pneumoniae
Young age + Haemolytic anaemia (comb test +) / jaundice
Mycoplasma pneumoniae
Old age + underlying lung disease / COPD
Hemophilus influenzae
Local outbreak in hotel industry or hospital/ history of travel / air-conditioner use / hyponatremia
Legionella pneumophila
H/O episode of influenza / viral illness/ IV drug users / cavitation
Staph aureus
Alcohol + DM+ Old age+ severe bacteraemic illness with cavitation
Klebsiella pneumoniae
Exposure to birds (often parrots)
Chlamydia psittaci
Farm workers / hide factory workers
Coxiella burnetii ( Q fever)
Sewage workers, farmers, animal handlers and vet
Leptospiral pneumonia
Exposure to infected hides, hair, bristle, bonemeal and animal carcases
Anthrax ( wool sorter’s disease)
Suppurative pneumonia or pulmonary abscess in previously healthy lung
Staph aureus / klebsiella pneumoniae
What are the markers of severity in pneumonia
○Confusion
○Urea > 7 mmol/L
○Respiratory rate > 30/min
○BP : SBP < 90 or DBP < 60 mmHg)
○Age > 65 years
○WBC : > 20 × 109/L or < 4 × 109/L
○Hyponatraemia
○Hypoalbuminemia
○Bacteraemia
Multilober shadowing, cavitation, pneumatoceles and abscesses
Staphylococcus aureus
Indications for referral to icu in pneumonia
• CURB score 4 or 5
• Persisting hypoxia
• Progressing hypercapnia
• Severe acidosis
• Circulatory shock
• Reduced conscious level
Antibiotic for low severity CAP CURB 0-1
Amoxicillin 500mg TDS
If allergic to penicillin
Doxycycline 200mg LD followed by 100mg bd or Clarithromycin 500mg bd
Antibiotic for moderate sverity CAP CURB 1-2
Amoxicillin 500mg TDS + Clarithromycin 500mg BD
If allergic to penicillin
Doxycycline + Levofloxacin 500mg OD
Antibiotic for severe CAP CURB 3-5
Co-amoxiclav 1.2 gm IV TDS / Cefuroxim 1.5 gm IV TDS / Ceftriaxone 1-2gm IV OD + Clarithromycin 500mg IV BD
Or,
Benzylpenicillin + levofloxacin
Chronic suppurative pulmonary inf + poor dental hygiene
Actinomyces sp.
Rx: IV / Oral penicillin for 6-12 months
What is the characteristic histological feature of suppurative pneumonia
Microabscess formation
Causes of progressive necrotising severe pneumonia
PVL producing strains of staph aureus
Associated with skin infection mainly
Sore throat + painful swollen neck + fever + rigour + haemoptysis + dyspnoea
Dx: Lemierre syndrome
C/O: Anaerobe Fusobacterium necrophorum
Rx: B lactum ab, metronidazole, clindamycin and 3rd gen cephalosporin
Its spread into jugular veins leads to thrombosis and metastatic dispersal of organism
First choice antibiotic for non severe symptoms in HAP
Co-amoxiclav
Immunocompromised pt with halo sign in HRCT
C/O: Aspergillosis
M. Bovis spread by
Drinking non-sterilised milk from infected cows
Ghon focus
Aggregation of numerous granuloma
Pale yellow
caseous nodule
usually a few mm to 1-2 cm in diameter
Situated at the periphery of lung
Primary complex Ranke
Combination of primary lesion + regional lymph node
How long does it take after TB infection to get positive tuberculin test
3-8 weeks
How long does it take after TB infection to form primary complex
3-6 weeks
How long does it take after TB infection to affect meninges, pleura and miliary TB
3-6 months
Which organ affects after 8 years of TB infection which is untreated
Renal tract
Which organ affects upto 3 years of TB infection which is untreated
GIT
Bone and Joint
Lymph node
How long does it take after TB infection to reactivate and cause post primary disease?
From 3 years onwards
Features of primary tuberculosis
Infection:
Influenza like illness
Primary complex formation
Skin test conversion
Disease:
Lymphadenopathy : hilar ( often unilateral), paratracheal, mediastinal.
Collapse ( right middle lobe)
Consolidation
Cavitation ( rare)
Obstructive emphysema
Pleural effusion
Meningitis
Pericarditis
Miliary disease
Hypersensitivity reaction:
Erythema nodosum
Phlyctenular conjunctivitis
Dactylitis
Miliary TB
Blood born dissemination
2-3 weeks of fever anorexia, night sweats, wt loss, dry cough
Hepatosplenomegaly
Headache - indicates coexistent tubercular meningitis
Anaemia and leucopenia : BM involvement
CXR- Fine 1-2 mm lesion (millet seeds) distributed throughout lung fields
Fundoscopy: choroidal tubercle
Post primary Pulmonary TB usually occurs on
Apex of an upper lobe
Causes of consolidation On CXR
Pulmonary TB
Pneumonia
Bronchial ca
Pulmonary infarct
Causes of miliary diffuse shadowing in CXR
Pulmonary TB
Sarcoidosis
Malignancy
Pneumoconiosis
Infection ( histoplasmosis, meliodosis)
Tropical Pulmonary eosinophilia
Causes of Cavitation on CXR
Pulmonary TB
Pneumonia / lung abscess
Lung carcinoma
Pulmonary infarct
GPA (wegner’s granulomatosis)
Progressing massive fibrosis
Causes of pleural effusion on CXR
Pulmonary TB
Bacterial pneumonia
Pulmonary infraction
Carcinoma
Connective tissue disease
What is the most common extrapulmonary site for TB
Lymph node
Cervical and mediastinal glands affect more frequently followed by axillary and inguinal
TB Symptoms + Rt iliac fossa mass
Dx: GI TB
Most common part: Ileocaecal disease
Inv: obtaining histology either by colonoscopy or mini laparotomy
D/D: crohns disease
TB symptoms + chronic back pain
Bone and Joint TB
Common site : Spine (lower thoracic and lumber spine)
Joint: Most frequently involves the hip or knee
What is the most imp first step for dx of TB
Direct microscopy of sputum smear
Which investigation is definitive for dx of TB
Culture or the detection of M. Tuberculosis DNA
Gold standard for drug sensitivity testing for TB
Culture
How long Rx is required for CNS TB?
12 months
When Glucocorticoid is recommended in TB
Constrictive pericarditis
CNS disease
Children with endobronchial disease
Rifampicin interacts with
It is a cytochrome P450 inducer, accelerating the metabolism of the following drugs,
Steroid
Oral hypoglycemic agent
Anti-retroviral
Warfarin
Opiates
Contraceptive
Isoniazid
M/A : Cell wall synthesis inhibitors
A/E: Major
Peripheral neuropathy (reduced by pyridoxine)
Hepatitis ( more common in alcoholics and patients with slow acetylator status)
Rash
Less common
Lupoid reaction
Seizures
Psychosis
Rifampicin
M/A: DNA transcription
A/E: Major
Hepatitis
Febrile reaction
Rash
GI disturbance
Less common
Interstitial nephritis
Thrombocytopenia
Hemolytic anaemia
All secretions become orange / red coloured
Pyrazinamide
M/A: Unknown
A/E: Major
Hepatitis (mostly)
GI disturbance
Hyperuricaemia
Less common:
Rash
Photosensitization
Gout
Ethambutol
M/A: Cell wall synthesis inhibitors
A/E: Major:
Retrobulbar neuritis
Arthralgia
Less common
Peripheral neuropathy
Rash
What is the first choice of investigation in LTB
IGRA
In the case of children’s Tuberculin test
TB IRIS TB- associated immune reconstitution inflammatory syndrome
Paradoxical increase in pre-existing. Or development of new, TB signs or symptoms due to ART reviving the immune system.
May be self limiting, but in severe cases steroids are used to reduce symptoms
Patients are advised to continue TB chemotherapy and ART
Wheezing / worsening of asthma + Productive cough / Bronchiectasis + ↑Eosinophil and IgE
Allergic Bronchopulmonary aspergillosis
Features:
Asthma
Proximal bronchiectasis
Positive skin test to extract A. Fumigatus
↑IgE
Peripheral blood eosinophilia
↑ A. Fumigatus specific IgE or IgG
Recovery of A. Fumigatus from sputum
Presence or H/O CXR abnormality
Mx:
Regular :Low dose oral Glucocorticoid
2nd line: Itraconazole
Exacerbations, Particularly with new CXR changes : Prednisolone (40-60mg)/ Day + physiotherapy
Immunocompromised+ new respiratory symptoms (pleural pain, haemoptysis) + fever+ HRCT shows macronodules surrounded by halo of intermediate attenuation
Invasive Pulmonary aspergillosis
Causes: severe necrotising pneumonia
Rx: DOC Voriconazole
CT findings:dense, well circumscribed lesion with or without Halo sign
Air cresent sign
Cavity
What is the most common form of lung carcinoma?
Adenocarcinoma
Blood born metastasis of lung ca usually occurs in
Liver
Bone
Brain
Adrenal
Skin
Which is the worst form of lung carcinoma and why?
Small cell carcinoma
Even a small primary tumor may cause widespread metastatic deposit
Horner syndrome
Features:
S- involvement of sympathetic nerve
A- Anhydrosis / Hypohydrosis of the face
M- Miosis
P- Ptosis (Ipsilateral, partial)
L- Loss of ciliospinal reflex
E- Enophthalmos
Cause: ca in the lung apex
Pancoast syndrome
Pain in the inner aspect of arms
Small muscle wasting in the hand
Indicate: malignant destruction of the T1 and C8 roots in the lower part of brachial plexus
Cause: Apical lung tumor
Non metastatic extrapulmonary manifestations of lung cancer
Endocrine:
Inappropriate ADH secretion causing hyponatraemia
Ectopic ACTH secretions
Hypercalcemia due to parathyroid hormone related peptide secretion
Carcinoid syndrome
Gynecomastia
Neurological :
Polyneuropathy
Myopathy
Cerebellar degeneration
Myesthenia (lambert eaton syndrome)
Others:
Digital clubbing
Hypertrophic Pulmonary osteoarthropathy
Neohrotic syndrome
Polymyositis
Dermatomyositis
Eosinophilia
Features suggestive of lung cancer in a smoker
Changes in characters of cough
Haemoptysis
Pneumonia that recurs at the same site or responds slowly to treatment
Investigation of choice for lung CA or Staging
CT Scan
Common radiological presentation of lung cancer
- Unilateral hilar enlargement
- Peripheral opacity or irregular cavitation
- Pleural effusion
- Lung, lobe or segmental collapse
5.:Pericardial effusion - Widening of upper mediastinum
- Elevation of hemidiaphragm
- Osteolytic rib lesion
Which tumors metastasize in lung
Breast
Kidney
Uterus
Ovary
Testes
Thyroid
Osteogenic
And other sarcoma
DPLD (diffuse parenchymal Lung Disease)
Clinical presentation:
Cough: usually dry, persistent, and distressing
Breathlessness: usually slowly progressive; insidious onset; acute in some cases
Examination findings:
●Crackles: typically bilateral and basal Inspiratory
●Clubbing
●Central cyanosis
Radiology
●CXR: typically small lung volumes with reticulonodular shadowing but may be normal in early or limited disease
●HRCT: Combinations of ground glass changes, reticulonodular shadowing, honeycomb cysts, and traction bronchiectasis, depending on the stage of disease
Pulmonary function :
○Typically restrictive ventilatory defect with reduced lung volumes and impaired gas transfer
○Exercise tests assess exercise tolerance and exercise-related fall in SaO2
Confirmatory Dx: Lung Biopsy
Persistent dry cough + Clubbing + Bibasal Inspiratory crackles + Restrictive lung function tests age>50 yrs
IDIOPATHIC PULMONARY FIBROSIS
Management
●Vital capacity between 50% and 80%: Pirfenidone (an antifibrotic agent) or nintedanib (a tyrosine kinase inhibitor) (SBA)
●Patients taking pirfenidone should be advised to avoid direct exposure to sunlight & use photoprotective clothing and high-protection sunscreens
●Nintedanib may be accompanied by diarrhea
Chronic cough + Mediastinal mass + Hypercalcemia + Erythema nodosum + Restrictive lung function
𝗦𝗔𝗥𝗖𝗢𝗜𝗗𝗢𝗦𝗜𝗦
Clinical features:
●Considered with other DPLDs, as over 90% of cases affect the lungs (SBA)
●Can involve almost any organ
●Löfgren syndrome: An acute illness characterized by
■Erythema nodosum
■Peripheral arthropathy
■Uveitis
■Bilateral hilar lymphadenopathy (BHL)
■Lethargy & occasionally fever
○Is often seen in young women.
●Fibrosis occurs in around 20% of cases of pulmonary sarcoidosis
●Complications: Bronchiectasis, aspergilloma, pneumothorax, pulmonary hypertension and cor pulmonale
Which investigation is used for staging of sarcoidosis?
CXR
Lymphopenia+ Hypercalcemia + Cobblestone appearance of mucosa found in?
Sarcoidosis
Erythema Nodosum+ BHL on CXR suggests
Sarcoidosis
Indication of immediate Prednisolone in sarcoidosis?
Dose: 20-40mg/Day
○Hypercalcemia
○Pulmonary impairment
○Renal impairment
○Uveitis
●Patients should be warned that strong sunlight may precipitate hypercalcemia and endanger renal function
Poor prognostic factors in sarcoidosis
○Age over 40
○African Caribbean ancestry
○Persistent symptoms for more than 6 months
○Involvement of more than three organs
○Lupus pernio
○Stage III/IV chest X-ray
Caplan Syndrome
Rheumatoid nodules+ Pneumoconiosis
Tropical pulmonary eosinophilia
●Causative Organism:
Wuchereria bancrofti or Brugia malayi (SBA)
● C/F:
fever, weight loss, dyspnea, and asthma-like symptoms
●Investigation:
○Marked peripheral blood eosinophilia
○Elevation of total IgE.
●Diagnosis may be confirmed by a response to treatment with diethylcarbamazine (6 mg/kg daily for 3 weeks)
Eosinophilic granulomatosis with polyangiitis (EGPA, formerly Churg–Strauss syndrome) Diagnostic Criteria
Eosinophilic granulomatosis with polyangiitis (EGPA, formerly Churg–Strauss syndrome), is diagnosed based on four or more of the following features:
○Asthma
○Peripheral blood eosinophilia >1.5 ×109/L (or >10% of a total white cell count)
○Mononeuropathy or polyneuropathy
○Pulmonary infiltrates
○Paranasal sinus disease
○Eosinophilic vasculitis on biopsy of an affected site
Byssinosis
Occurs in workers of cotton and flax mills exposed to cotton brack (dried leaf and plant debris)
Farmer / Bird owner + Influenza like symptoms / Cough, breathlessness & wheeze + End Inspiratory crackles + Restrictive lung function
𝗛𝗬𝗣𝗘𝗥𝗦𝗘𝗡𝗦𝗜𝗧𝗜𝗩𝗜𝗧𝗬 𝗣𝗡𝗘𝗨𝗠𝗢𝗡𝗜𝗧𝗜𝗦
(𝗘𝘅𝘁𝗿𝗶𝗻𝘀𝗶𝗰 𝗮𝗹𝗹𝗲𝗿𝗴𝗶𝗰 𝗮𝗹𝘃𝗲𝗼𝗹𝗶𝘁𝗶𝘀)
●Common causes include farmer’s lung and bird fancier’s lung
●Consistent with both type III & type IV immunological mechanisms
●Precipitating IgG antibodies may be detected in serum
●A type III Arthus reaction is believed to occur in the lung
Investigation
●CXR: ill-defined patchy airspace shadowing, pneumonia.
●HRCT: Bilateral ground glass shadowing & areas of consolidation superimposed on small centrilobular nodular opacities with an upper and middle lobe predominance and mosaicism
●Pulmonary function tests: Restrictive
●Positive serum IgG
●BAL fluid: Usually shows an increase in CD8+ T lymphocytes
MX: reduce exposure and prednisolone
Causes of pulmonary embolism
DVT (venous thromboembolism) most common
Septic emboli (Endocarditis)
Choriocarcinoma
Fat Following Fracture of Long Bones
Air and amniotic fluid following delivery
ECG findings on Pulmonary Embolism
Most common findings:
Sinus tachycardia and Anterior T-wave inversion
Large emboli cause
S1 Q3 T3 pattern
ST segment and T wave changes
RBBB
Mx of Pulmonary thromboembolism
Main principle of treatment : anticoagulation therapy
Acute massive PE with hemodynamic instability : thrombolysis
Recurrent VTE/ contraindicated anticoagulation therapy : inferior vena cava filter
In Pregnancy : LMWH
Wedge shaped opacity in CXR seen in
Pulmonary thromboembolism
Pulmonary hypertension
Def: Mean Pulmonary arterial pressure (PAP) at least 25 mmHg at rest
Measured by: Right heart catheterization
Most common cause: Respiratory failure due to intrinsic Pulmonary disease
Age: 20-30
Sex: mainly women
Clinical features of Pulmonary Hypertension
Clinical features
●Typical symptoms: breathlessness, chest pain, fatigue, palpitations, exertional dizziness and syncope
●Important signs
○Elevation of JVP (prominent ‘a’ wave)
○Parasternal heave (right ventricular hypertrophy),
○Loud P2
○Right ventricular third heart sound
○Peripheral edema and ascites
What is the confirmatory investigation for Pulmonary Hypertension?
Investigation
○ECG: Right ventricular ‘strain’ pattern
○CXR: Enlarged pulmonary arteries, peripheral pruning & right ventricle enlargement
○Transthoracic echocardiography provides a non-invasive estimate of PAP (SBA)
○Right heart catheterization: Confirmatory (SBA)
Management
● Oxygen Supplement
●Drugs for PH
○Diuretics if Heart Failure
○Anticoagulation
○ Digoxin if Arrhythmia
○With acute vasodilator response: High dose CCB (SBA)
○Endogenous Prostacyclins replaced by: epoprostenol, treprostinil, or iloprost
○Blocking endothelin-mediated vasoconstriction: Bosentan, ambrisentan, or macitentan (SBA)
○Enhancing endogenous nitric oxide-mediated vasodilatation by Phosphodiesterase V inhibitors: Sildenafil or tadalafil
○Or Guanylate cyclase stimulator: Riociguat
Obstructive sleep apnoea/hypopnoea syndrome
Cause:
Results from recurrent occlusion of the pharynx during sleep, usually at the level of the soft palate
●Predisposing factors
○Male gender, Obesity
○Nasal obstruction or a recessed mandible
○Acromegaly, Hypothyroidism
○Alcohol, Sedatives
○Familial, where the maxilla & mandible are back-set
●Complications
○Marked sympathetic activity > Sustained HTN > Increased risk of coronary events & stroke
○Insulin resistance
○Metabolic syndrome
○Type 2 DM
●Diagnosis: Polysomnography / Overnight studies of breathing, oxygenation, and sleep quality (SBA)
●Gold standard therapy : Continuous positive airway pressure (CPAP) (SBA)
Respiratory distress + Normal lung findings + Normal CXR
Pulmonary embolism»_space;> CTPA
