Respiratory Flashcards

Question

What is Alpha 1 antitrypsin deficiency? | and what 2 organs does it affect.

Answer 1

* Alpha-1 antitrypsin deficiency is a genetic condition caused by low levels of alpha-1 antitrypsin. * Chronic obstructive pulmonary disease and bronchiectasis in the **lungs** (typically after 30 years old) * Dysfunction, fibrosis and cirrhosis of the **liver** (depending on the specific genotype)

Answer 2

* Autosomal Co dominant condition affecting SERPINA1 gene on Chromosome 14 * A1AT (protease inhibitor) which protects cells from enzymes (neutrophil elastase) - is now low in number or non existent * In lungs excess protease enzymes (elastase)-> attack connective (elastin) tissue -> bronchieactasis and emphysema * in liver an abnormal mutant version of A1AT is made that gets trapped and builds up inside the liver cells (hepatocytes). These are toxic to the hepatocytes ->inflammation -> fibrosis -> cirrhosis and potentially hepatocellular carcinoma. * Liver pathology can occur at any age, including childhood | Lungs: deficient A1AT Liver: defunct A1At ## Footnote Less common association * Panniculitis (tender skin nodules caused by inflammation of the subcutaneous fat) * Granulomatosis with polyangiitis (a small and medium vessel vasculitis)

Answer 3

* lungs: panacinar emphysema, most marked in **lower lobes** * liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children * **Think of COPD picture in young nonsmoker** * SOB, Wheeze, Mucus | panacinar: whole acinar (alveoli)

Answer 4

* Low serum alpha-1 antitrypsin (the screening test) * Genetic testing * spirometry: obstructive picture ## Footnote Liver biopsy shows periodic acid-Schiff positive staining globules in hepatocytes, resistant to diastase treatment. These represent a buildup of the mutant proteins.

Answer 5

* no smoking * supportive: bronchodilators, physiotherapy * intravenous alpha1-antitrypsin protein concentrates * surgery: lung volume reduction surgery, lung transplantation

Answer 6

* Emphysema is most promiment in the lower lobes of the lungs with A1AT deficiency * Usually seen in upper lobes with COPD

Answer 7

Aggresive cancer which affects the mesothelium (mesothelial layer) around the lungs and pleural cavity | linked to asbestos exposure.

Answer 8

* Exposure from construction material (most cases lying dormant) * Asbestos material is very thin and jagged so gets into interstitial space * from where it gets into thin epithelial layer * Due to size they never get metabolised so affect individual later on in life * Mesothelial Plaques are formed * these release Calretinin - which helps differentiate mesothelioma from other cancers | * Asbestos can affect other organs elsewhere but commonly affects lungs ## Footnote Unlike smoking risk of cancer is reduced as you stop but asbestos remains dormant and unmetabolised so the risk is everpresent.

Answer 9

* Dysnpnoea * Weight loss * Clubbing * Haemoptysis * Pleural Effusion * More common in R Lung | Metastases to contralateral lung and peritoneum ## Footnote History of asbestos exposure in 85-90%, latent period of 30-40 years

Answer 10

* Chest x-ray showing either a pleural effusion or pleural thickening * Perform Pleural CT * Local anaesthetic thoracoscopy is increasingly used to investigate cytology negative exudative effusions as it has a high diagnostic yield (around 95%) | Xray in some cases shows pneumothrax ## Footnote if an area of pleural nodularity is seen on CT then an image-guided pleural biopsy may be used

Answer 11

* Symptomatic * Industrial compensation * Chemotherapy, Surgery if operable * Prognosis poor, median survival 12 months

Answer 12

Chronic Obstructive Pulmonary Disease is a **Irreversible obstructive** lung condition - umbrella term which includes both emphysema and chronic bronchitis. * Chronic Bronchitis; inflamed airway -> excess mucus, sputum, chronic cough. * Emphysema; Damage to the elastin -> alveoli and alveoli sacs | classed as partially reversible by some but unlike asthma ## Footnote Risk Factors * Smoking (biggest) * Alpha 1 antitrypsin deficiency * Pollutants like; dust, coal, cotton, cement.

Answer 13

* Constant exposure to pollutant (smoking) causes **Hypertrophy & Hyperplasia** of Respiratory Tract * This causes increase in **Mucus glands and Goblet cells** -> More Mucus production * Hypertrophy + Hyperplasia -> **Cilliary Dysfunction** (mucus less motile) so mucus plugs airways * O2 can't get through to Alveoli coz of these plugs, CO2 can't get out = **Air trapping** * CO2 Buildup leads to V/Q mismatch due to low perfusion (Q) -> **Hypercapnia + Hypoxaeimia**

Answer 14

* Pollutant (smoke) enters airways -> **Macrophages phagocytose** pollutant * Phagocytosis causes release of **Cytokines** and **Neutrophils** -> Inflammation * CKs & Neutrophils releaee proteases including Neutrophil Elastase -> breaks down elastin. * Lungs lose ability to recoil - keading to **airway collapse** and **air trapping** **Bernoulies Principle**: - relates to **increased airflow velocity** in narrowed airways, leading to decreased pressure and contributing to airway collapse due to the loss of elastic recoil in the damaged lung tissues - Airway Collapse -> CO2 unable to leave -> **Hypercapnia + Hypoxaemia** ( Develops in later stage) ## Footnote 1. Centriacinar Emphysema 2. Panacinar Emphysema 3. Distal Acinar Emphysema - risk of **Pneumothrax**

Answer 15

* With Chronic Bronchitis there is an increased risk of Pneumonia 1. Haemophilus influenzae - **MOST common** 2. Streptococcus pneumoniae 3. Moraxella catarrhalis

Answer 16

**Bronichitis** - Obesity - Inspiratory Crackles - Cyanosis **Emphysema** - Pink skin - due to pursed lip breathing and easy to get air in but hard to get air out. - Skinny - Weight loss **Both** - Wheezing - expiratory - SOB - Dyspnoea - Hyperresonance on percussion - Increased AP diameter | severe cases, right-sided HF, may develop resulting in peripheral oedema ## Footnote COPD doesn't cuase clubbing, haemoptysis, Chest pain.

Answer 17

* Usually Clinical Diagnosis aided with investigations * Post-bronchodilator spirometry to demonstrate airflow obstruction: **FEV1/FVC ratio less than 70%.** * Irreversible Obstruction so unlike asthma ratio will not improve. * FEV1 and FVC both low * Full blood count: exclude **secondary polycythaemia** * CT and CXR to rule out other modalities

Answer 18

* Stage 1 (mild): FEV1 more than 80% of predicted * Stage 2 (moderate): FEV1 50-79% of predicted * Stage 3 (severe): FEV1 30-49% of predicted * Stage 4 (very severe): FEV1 less than 30% of predicted | Stage 1: Diagnosis only if Symptoms present.

Answer 19

* Hyperinflation * Bullae - Singular Bulla (sometimes mimic Pneumothorax) * Flat hemodiaphragm * Important as CXR rules out Lung Cancer and other pathologies

Answer 20

* Smoking cessation advice (nicotine patches) * Annual Flu Vax * Pneumococcal Vax * Pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD * Consider Inhaler therapy after all this

Answer 21

1. SABA + SAMA 2. Depending on previous history (asthma/steroid) response - No asthmatic resposnse: LABA + LAMA (+SABA) - Asmatic/Steroid Response: LABA + ICS (+SABA/SAMA) 3.. LABA + LAMA + ICS inhaler (+SABA) ## Footnote short acting beta agonist - Salbutamol short acting muscarinic antagonist - Ipratropium Bromide long acting beta agonist - Salmetarol long acting muscarinic antagonist - Tiotropium ICS - Fluticasone

Answer 22

* any previous, secure diagnosis of asthma or of atopy * a higher blood **eosinophil** count - note that NICE recommend a full blood count for all patients as part of the work-up * substantial variation in FEV1 over time (at least 400 ml) * substantial diurnal variation in peak expiratory flow (at least 20%)

Answer 23

* Oral **Theophyline** * Prophylactic Abx: **Azithromycin** * Mucolytics: **Carbocyteine** - break down mucus * Oral PDE-4 inhibitors - **Roflumilas** | Specialist cases guided by experts

Answer 24

* LFTs and an ECG to exclude QT prolongation should be done as azithromycin can prolong the QT interval | to be done before treatment and during

Answer 25

* Hypoxia O2 <92% * FEV1 <30% * Polycythaemia * Cyanosis * Cor Pulmonale Perform ABGx2 3wks apart * <7.3KPA O2 = LTOT * 7.3-8 KPA O2 (symptoms as above incl. Pulmonary HTN, Peripherall Oedema, 2ndry Polycythaemia) = LTOT | Falls because you can trip on wires and smoking because O2 is flammable

Answer 26

Hypoxaemic Vasoconstriction (increased pressure and resistance in the pulmonary arteries)-> Pulmonary Hypertension -> RV Hypertrophy -> RHF -> Cor Pulmonale. ## Footnote **Cor Pulmonale Presentation** * Shortness of breath * Breathlessness of exertion * Syncope (dizziness and fainting) * Chest pain * Hypoxia * Cyanosis * Raised JVP (due to a back-log of blood in the jugular veins) * Peripheral oedema * Parasternal heave * Loud second heart sound * Murmurs (e.g., pan-systolic in tricuspid regurgitation) * Hepatomegaly due to back pressure in the hepatic vein (pulsatile in tricuspid regurgitation)

Answer 27

* Nebulised SABA * GIve **prednisolone 30 mg** daily for **5 days** * Oral antibiotics 'if sputum is purulent or there are clinical signs of pneumonia' * **IV hydrocortisone** may sometimes be considered instead of oral prednisolone * **IV theophyline/Aminophylline** - If no response to nebuliser | often triggred by viral or bacterial Ix. ## Footnote Patients with COPD are prone to develop type 2 respiratory failure. If this develops then non-invasive ventilation **NIV** may be used * Typically used for COPD with respiratory acidosis pH 7.25-7.35 + PaCO2 >6

Answer 28

- In a normal COPD pt you would give **Venturi mask** which allows better control as you can deliver specific amount - Low SATS despite treatment then treat with **High flow O2 - via Non breather mask** - Consider **NIV** in patients with acute hypercapnia and unresolving hypoxaemia - if NIV fails consider **intubation**, **ventilation**, and **ICU** or whether **palliative care** is more appropriate. ## Footnote - Patients should have a chest x-ray before NIV to exclude pneumothorax. - ABGs every hour until stable then every 4 hours. - whilst on non-invasive ventillation

Answer 29

* COPD patients are at risk of **hypercapnia** - therefore an initial oxygen saturation target of 88-92% should be used * Adjust target range to 94-98% if the pCO2 is normal * Use Venturi Masks ## Footnote Venturi masks are designed to deliver a specific percentage concentration of oxygen. They allow some of the oxygen to leak out the side of the mask and normal air to be inhaled along with oxygen. Environmental air contains 21% oxygen. Venturi masks deliver 24% (blue), 28% (white), 31% (orange), 35% (yellow), 40% (red) or 60% (green) oxygen.

Answer 30

* **Low pH** indicates acidosis * **Low pO2** indicates hypoxia and respiratory failure * **Raised pCO2** indicates CO2 retention (hypercapnia) * **Raised bicarbonate** indicates chronic retention of CO2 ## Footnote * Low pH with a raised pCO2 suggests they are acutely retaining CO2 - Resp Acidosis * Raised bicarbonate indicates they chronically retain CO2 (theoretically normal pH) However: During an acute exacerbation, the kidneys cannot keep up with the rising level of CO2, so the blood becomes acidotic despite a raised bicarbonate.

Answer 31

- Permanent Dilation of the Bronchi - Often caused by damage (inflammation, infection) to the lungs - Sputum collects and organisms grow in bronchi -> chronic cough, continuous sputum production and recurrent infections. ## Footnote TOM TIP: The key features to remember with bronchiectasis are finger clubbing, diagnosis by HRCT, Pseudomonas colonisation and extended courses of 7-14 days of antibiotics for exacerbations.

Answer 32

* Pneumonia * Pertussis * Could be Idiopathic * Measels * Connective Tissue Disorder * Cystic Fibrosis * Yellow Nail Syndrome The correct answer is bronchiectasis. This patient presents with chronic cough productive cough for the last three months, with occasional haemoptysis, on a background of premature birth and consequent multiple chest infections. These are characteristic features and risk factors of bronchiectasis

Answer 33

* Bronchiectasis * Yellow Nails * Lymphoedema

Answer 34

Symptoms * Persisent Chronic Productive cough - Sputum * Dyspnoea * Recurrent Chest Ix Signs * Clubbing * Cachexia - weight loss * Scattered Crackles + Wheezing (abnormal) ## Footnote Usually leads to Cor Pulmonale - due to Pulmonary HTN

Answer 35

**CXR**: Ring Shadows + Tram Track Opacities **Sputum**: *H. Influenzae Pseudomonas Aerigunosa* **Gold Standard**: High Rest CT Chest

Answer 36

* Vaccinate: Flu + Pneumococcal * Respiratory Physiotherapy: Postural drainage * Prophylctic Abx: Azithromyocin * Inspiratory Muscle Training

Answer 37

* Usually Infective Exacerbations 1. Sputum culture 2. Abx - extended course 7-14 days 3. Ciprofloxacin - usually for *P. Aerigunosa* | Haemophilus Influenza and Pseudomonas Aeirugunosa common ones

Answer 38

**Small Cell Lung Cancer** (20%) - worse prognosis + associated with smoking **Non Small Cell Lung Cancer** (80%) Most common Further Divided into: 1. Adenocarcinoma - most common in non smokers 2. Squamous Cell Carcinoma - cavitating leisons 3. Large Cell Carcinoma 4. Alveolar cell carcinoma 5. Bronchial adenoma

Answer 39

* Dyspnoea * Cough * Haemoptysis * Weight loss * Hoarse Voice (pancoast tumour) * Superior Vena Cava Syndrome **Examination** - Fixed monophonic wheeze may be noted - Lymphadenopathy (supraclavicular nodes) - Finger clubbing

Answer 40

Paraneoplastic syndromes are rare clinical conditions associated with specific cancers, where remote effects, such as neurological or endocrine manifestations, arise due to the production of bioactive substances by tumor cells or the host's immune response to the tumor. ## Footnote Small-cell lung cancer cells contain **neurosecretory granules** that release neuroendocrine hormones. **SCLC may be responsible** for various paraneoplastic syndromes.

Answer 41

Small Cell * ADH secretion -> SIADH (hyponatraemia) * ACTH Secretion -> Cushing's * Lambert-Eaton myasthenic syndrome is caused by antibodies against small-cell lung cancer cells. * Limbic encephalitis is caused by antibodies against small-cell lung cancer cells. Squamous cell * parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia * clubbing * hypertrophic pulmonary osteoarthropathy (HPOA) Adenocarcinoma * Gynaecomastia * hypertrophic pulmonary osteoarthropathy (HPOA) ## Footnote Superior vena cava obstruction is a complication of lung cancer. It is caused by direct tumour compression on the superior vena cava. It presents with facial swelling, difficulty breathing, and distended neck and upper chest veins. Pemberton’s sign is where raising the hands over the head causes facial congestion and cyanosis. SVC obstruction is a medical emergency. Horner’s syndrome is a triad of **partial ptosis, anhidrosis and miosis**. It can be caused by a Pancoast tumour (tumour in the pulmonary apex) pressing on the sympathetic ganglion.

Answer 42

CXR within 2 weeks for patients: * Over 40 * Clubbing * Lyphadenopathy * Recurrent Chest Ix's * Chest signs of lung cancer | Urgent chest x-ray: finger clubbing and supraclavicular lymphadenopathy. ## Footnote Offer CXR for 40+ with 2 unexplained symptoms (cough, SOB, Chest pain, Fatigue) 1 unexplained symptom for 40+ Smoker

Answer 43

**CXR**: Hilar enlargement, peripheral opacity, pleural effusion, collapse. **CT**: ***Investigation of choice*** - allows tumour staging (TMN) and to see lymph node involvement **Bronchoscopy**: allows biopsy for histological diagnodid **PET Scanning**: usually in NSCLC to establish treatment path **Bloods**: Increased Platelets.

Answer 44

* usually central * arise from APUD* cells

Answer 45

Squamous Cell: Central Adenocarcinoma: Typically Peripheral, most common in non smokers but most people who develop it are smokers Large cell: Peripheral, poor prognosis ,may secrete beta hCG.

Answer 46

* usually metastatic disease by time of diagnosis * patients with very early stage disease (T1-2a, N0, M0) are now considered for surgery. NICE support this approach in their 2011 guidelines * however, **most patients with limited disease receive a combination of chemotherapy and radiotherapy** * patients with more extensive disease are offered palliative chemotherapy

Answer 47

* 20% suitable for surger * Curative or palliative radiotherapy * poor response to chemotherapy ## Footnote **Surgery contraindications** * assess general health * stage IIIb or IV (i.e. metastases present) * FEV1 < 1.5 litres is considered a general cut-off point* * malignant pleural effusion * tumour near hilum * vocal cord paralysis * SVC obstruction

Answer 48

A thoracotomy scar in your OSCEs indicates either a lobectomy, pneumonectomy or lung volume reduction surgery for COPD. A right-sided mini-thoracotomy incision in a cardiology station likely means minimally invasive mitral valve surgery. Absent breath sounds on an entire side indicates a pneumonectomy. Focal absent breath sounds suggest a lobectomy. Lobectomies and pneumonectomies are used to treat lung cancer. Previously, they were used to treat tuberculosis, so remember this in older patients.

Answer 49

* Ix caused by Mycobacterium tuberculosis - which commonly affects lungs * **Primary**: Infection in lungs - leison called Ghon focus develops (ghon complex) - in healthy pt's healng is via fibrosis, in imunnocompromised they may develop disseminated disease (miliary tuberculosis) * **Seconday**: Usually post-primary. latent Ix gets reactivated when pt becomes immunocompromised. Usually occurs in Apex of lungs but can occur in: * central nervous system (tuberculous meningitis - the most serious complication) * vertebral bodies (Pott's disease) * cervical lymph nodes (scrofuloderma) * renal * gastrointestinal tract | Tuberculosis is spread by inhaling saliva droplets from infected people. ## Footnote Risk Factors * Close contact with active tuberculosis (e.g., a household member) * Immigrants from areas with high tuberculosis prevalence * People with relatives or close contacts from countries with a high rate of TB * Immunocompromised (e.g., HIV or immunosuppressant medications) * Malnutrition, homelessness, drug users, smokers and alcoholics

Answer 50

* Small rod-shaped bacteria (bacillus) * High O2 requirement so difficult to culture in lab * Has a waxy coating that makes gram staining ineffective - as theyre acid fast * **Ziehl-Neelsen Stain** - Bright red on blue background is gold standard | Acid Fast bacilli

Answer 51

* Cough * Haemoptysis * Lethargy * Night sweats * Weight loss * Lymphadenopathy * Erythema Nodusum: Red nodules on shin * Spinal tuberculosis: Pott's disease of the spine. ## Footnote Tuberculosis typically presents with chronic, gradually worsening symptoms. Most cases involve pulmonary disease, often with systemic symptoms.

Answer 52

* Macrophages migrate to regional lymph nodes forming ghon complex * which forms Granukma with caseous necrosis in the centre * Type 4 Hypersensitivity rxn

Answer 53

* Bacillus Calmette–Guérin (BCG) vaccine involves an intradermal injection of live attenuated (weakened) **Mycobacterium bovis** bacteria * Relative of M. Tuberculosis - not a diseases causer in humans * Creates immune response against M. Tuberculosis * Pt must be **Mantoux: -ve** * It is not part of the routine vaccination schedule. * Offered to patients at increased risk of TB, such as those from areas of high TB prevalence, with close contact with TB ## Footnote The vaccine protects against severe and complicated TB but less against pulmonary TB.

Answer 54

* **Mantoux test**: IM of PPD - results 72h later - >15mm induration = +ve for TB * False -ve's: sarcoidosis, HIV, Lymphoma so you do: * **Inferon Gamma test**: +ve result when Inferon gamma released when mixing blood sample

Answer 55

* **CXR**: Upper lobe cavitation & bilateral hilar lymphadenopathy * **Sputum smear**: 3 specimens, rapid, ziehl neels stain (red), decresed sensitivity in HIV * **Sputum culture**: can take 1-3 weeks, can assess drug sensitivity, more sensitive than smear and NAAT | Sputum culture is gold standard. ## Footnote Deep cough sputum req'd. If not possible then: **Sputum induction** with nebulised hypertonic saline **Bronchoscopy and bronchoalveolar lavage** (saline is used to wash the airways and collect a sample)

Answer 56

* **Primary tuberculosis** may show patchy consolidation, pleural effusions and hilar lymphadenopathy. * **Reactivated tuberculosis** may show patchy or nodular consolidation with cavitation (gas-filled spaces), typically in the upper zones. * **Disseminated miliary tuberculosis** gives an appearance of millet seeds uniformly distributed across the lung fields.

Answer 57

* Rifampicin - 6m * Isoniazid - 6m * Pyrazinamide - 2m * Ethambutol - 2m | pyridoxine/vitamin B6 co-prescribed ## Footnote * Home isolation for 2 wk or based on med team advice * In hospitals, negative pressure rooms are used to prevent airborne spread. Negative pressure rooms have ventilation systems that actively remove air to prevent it from spreading onto the ward.

Answer 58

* 3 months of Isoniazid + pyridoxine + rifampicin OR * 6 months of Isoniazid + pyridoxine ## Footnote Pt w/ Latent disease cannot pass the disease on to others, so there is no restriction in terms of employment

Answer 59

**Rifampicin** * potent liver enzyme inducer * hepatitis * red/orange secretions (urine/tears) * flu-like symptoms **Isoniazid** * peripheral neuropathy: prevent with pyridoxine (Vitamin B6) * hepatitis, agranulocytosis * liver enzyme inhibitor **Pyrazinamide** * hyperuricaemia causing gout * arthralgia, myalgia * hepatitis **Ethambutol** * optic neuritis: check visual acuity before and during treatment

Answer 60

* **Mid axillary line** of the **5th intercostal space** Bordered by: Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla. | Inserted using anatomical guidance or through ultrasound guidance ## Footnote Triangle is formed by * The 5th intercostal space (or the inferior nipple line) * The midaxillary line (or the lateral edge of the latissimus dorsi) * The anterior axillary line (or the lateral edge of the pectoralis major)

Answer 61

* Inflammory condition of the lungs (alveoli) - 2ndry to infection. * **Community-acquired pneumonia (CAP)** develops in the community * **Hospital-acquired pneumonia (HAP)** develops after more than *48 hours* in a hospital * **Ventilator-acquired pneumonia (VAP)** develops in intubated patients in the intensive care unit * **Idiopathic interstitial pneumonia**: non-infective cause, e.g cryptogenic organising pneumonia developing with R Arthritis or amiodarone therapy. * **Aspiration Pneumonia** Ix develops due to aspiration of food/fluids in pt with impaired swallowing. | it's classed as LRTI ## Footnote Can be bacterial, Viral or Fungal

Answer 62

* **Streptococcus pneumoniae**: 80% of cases - most common CAP- seen with Herpes labialis. AKA Pneumococcus (vaccine available) * **Haemophilus influenzae**: common in COPD * **Staphylococcus Aureus** Post Influenza Ix. * **Mycoplasma pneumoniae** atypical pneumonia (diff signs) * **Klebsiella pneumoniae** Classically seen in alcoholics * **Pneumocystis jiroveci**: patients with HIV

Answer 63

* Pathogen enters LRT * Neutrophils migrate to Infected alveoli -> Relase Cytokines -> Immune response -> Inducing fever * This process leads to accumulation of fluid and pus. * impaired gaseous exchange -> hypoxia ## Footnote RF * Smoking * Age <5 or >65Y * recent viral ix * COPD and CF * Immunosupressed * IV drug users

Answer 64

**Symptoms** * Cough (purulent sputum - rusty) * Dyspnoea * Chest pain (?pleuritic) * Fever Malaise **Signs** * Tachycardia, Hypotension, High temp * Tachypnoea (Increase RR) * Low O2 sats * **Dullness on percussion** (due to fluid filled lungs) * Reduced breath sounds ( (harsh inspiratory and expiratory breath sounds) due to consolidation around the airways) * **Bronchial breathing & Crepitations/Crackles**(caused by air passing through sputum filled airways)

Answer 65

* **C**onfusion * **U**rea >7mmol * **R**espiratory Rate >30pm * **B**lood Pressure <90/<60 * Age: >**65** | Usage: CRB-65 in Primary and CURB-65 in secondary care ## Footnote NICE Recommendation Home care for: 0 or 1 Hospital Care >2 Intensive Care >3 (High risk)

Answer 66

**CXR:** * Consolidation (opacity) * Effusion **Bloods:** * FBC: Raised WCC (Ix) * U&E: Urea for CURB65 * CRP: Raised. Used for monitoring to see abx response * Blood cultures * Renal Profile: Asses AKI **Sputum Sample:** * Diagnose causative organism ## Footnote CRP < 20 mg/L - No Abx CRP 20 - 100 mg/L - consider a delayed antibiotic prescription CRP > 100 mg/L - offer antibiotic therapy

Answer 67

Low Severity: * **Amoxicillin 5 day** course * (macrolide/tetracycline in allergy) Moderate/High: * Hospital IV treatment * Dual Abx therapy - **Amoxicillin + Macroclide** (azithromycin) * **7-10 day** course * consider beta-lactamase stable penicillin such as **co-amoxiclav** in high severity ## Footnote Discharge Criteria * 1 week Fever should have resolved * 4 weeks Chest pain and sputum production should have substantially reduced * 6 weeks Cough and breathlessness should have substantially reduced * 3 months Most symptoms should have resolved but fatigue may still be present * 6 months Most people will feel back to normal. - Repeat CXR at 6wks post treatment to assess.

Answer 68

* Sepsis * Acute respiratory distress syndrome * Pleural effusion * Empyema * Lung abscess * Death Post treatment bloods: C-reactive protein shows a lag in decreasing in comparison to the white cell count in treatment of acute bacterial infection

Answer 69

* Pprogrsive fibrosis of interstitium of the lungs with no apparent cause * chronic inflammation -> fibroblasts triggered -> excess collagen + ecm protein production -> scar tissue formation -> destroys architecture and elasticity of lungs. * Seen in 50-70y. common in M | Restrictive Lung disease ## Footnote What reduced elasticity here means excess collagen makes them more stiff so can't take in as much gas compared to emphysema for example

Answer 70

* Spirometry shows restrictive picture: Decreased FVC and Same/Decreased FEV1 * FEV1/FVC ratio >0.8 * CXR: bilaterla interstitial shadowing. Groundglass -> honeycomb appearance * High res CT: Gold standard ## Footnote ANA positive in 30%, rheumatoid factor positive in 10% but this does not necessarily mean that the fibrosis is secondary to a connective tissue disease. Titres are usually low

Answer 71

* Progressive Dyspnoea * Bibasal **fine** end inspiratory **crepitations** * Dry cough * clubbing

Answer 72

* Pulmonary Rehab * Supplementary O2 Medication which may slow progression of disease. * **Pirfenidone** reduces fibrosis and inflammation through various mechanisms * **Nintedanib** reduces fibrosis and inflammation by inhibiting tyrosine kinase ## Footnote Prognosis is poor. Life expectancy is around 4y

Answer 73

* Multisystem disorder of unknown aetiology * Chronic granulomatous disorder. Granulomas are inflammatory nodules full of macrophages. * Usually associated with Respiratory symptoms but has others such as: erythema nodusum, lymphadenopathy ## Footnote Epidemiology * Aged 20-39 or around 60 * Women * Black ethnic origin

Answer 74

* **Bilateral hilar lymphadenopathy** * **Dynspnoea, cough, malaise, wt loss** * **Erythema nodosum**: inflamed nodules on the shins. (raised, red, painful) * **Lupus pernio** specific to sarcoidosis: raised purple skin lesions on cheeks and nose. * **Hypercalcaemia** * **Lung fibrosis** * **Bundle branch block** * **Uveitis, optic neuritis** * **Liver nodues & cirrohosis**

Answer 75

**Lofgren's syndrome** is an acute form of the disease characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis In **Mikulicz syndrome*** there is enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma **Heerfordt's syndrome** (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis | Mikulicz syndrome likended to Sjiorgens

Answer 76

* **ACE** used as monitoring disease activity and not diagnosis * Raised **ESR and Ca2+** **CXR** * stage 0 = normal * stage 1 = bilateral hilar lymphadenopathy (BHL) * stage 2 = BHL + interstitial infiltrates * stage 3 = diffuse interstitial infiltrates only * stage 4 = diffuse fibrosis **spirometry**: may show a restrictive defect **tissue biopsy**: non-caseating granulomas

Answer 77

**Steroid treatment** - Pt with CXR stage2-3 + symptoms - Asymptoatic stage 2-3 no treatment Methotrexate second line | +Bisphosphonate bcz long term steroids ## Footnote Self resolving within 2y for 50% patients or leads to pulmonary HTN -> fibrosis Poor Prognosis - insidious onset - no erythema nodusum - CXR Stage 3-4 - Black

Answer 78

* increased resistance and pressure in the pulmonary arteries * causing strain on RHS of the Heart * Causes: Idiopathic, COPD, Fibrosis, PE, Sarcoidossis | Mean pulmonary arterial pressure **>20 mmHg.**

Answer 79

* Dyspnoea * Syncope * Tachycardia * Raised JP * Hepatomegaly * Peripheral Oedema ECG: P pulmonale (peaked p waves). right axis deviation, RBBB CXR: Dilated Pulmonary arteris, RV Hypertrophy ECHO: meausure Pulmonary Artery Pressure

Answer 80

Idiopathic * CCB * IV Prostaglandins (epoprostenol) * Phosphodiesterase-5 inhibitors (e.g., sildenafil) Secondary pulmonary hypertension is managed by treating the underlying cause, such as pulmonary embolism, COPD or systemic lupus erythematosus. ## Footnote Supportive treatments (e.g., oxygen and diuretics) are used for complications such as respiratory failure, oedema and arrhythmias.

Answer 81

* Abnormal fluid in the pleural space, other than the normal pleural fluid * Fluid is divided into 2 categories 1. **Transudative**: lower protein content (<30g/L) 2. **Exudative**: a high protein content (> 30g/L) ## Footnote Pleural fluid is secreted by mesothelial cells from both pleural layers and acts to lubricate their surfaces. This lubrication reduces friction between the two layers to prevent trauma during breathing, and creates surface tension that helps maintain the position of the lungs against the thoracic wall.

Answer 82

**Exudative**: (Due to Inflammation -> Proteins leaks out of tissue into pleural space) * Cancer * Pnemonia - most common * Tuberculosis * Rheumatoid Arthritis & SLE (Cnective Tissue disorders) * yellow nail syndrome * PE **Transudative**: (fluid move across/shifting into pleural space) * Congestive HF - most common * Hypoalbuminaemia * Hypothyroidism * Meigs syndrome | Lights criteria used for establishing an exudative effusion using LDH ## Footnote Meigs syndrome involves a triad of a benign ovarian tumour (usually a fibroma), pleural effusion and ascites. This often appears in exams. The pleural effusion and ascites resolve with the removal of the tumour.

Answer 83

* Dyspnoea * Chest Pain * Non-productive Cough * Dullness on chest percussion * Reduced Breath sounds * Tracheal Deviation (in larger effusions) * Reduced Chest Expansion

Answer 84

CXR: (to be done P->A) * blunting of costrophrenic angle * fluid in lung fissures * larger ones will have meniscus at bottom USS: Preferred * likelihood of successful pleural aspiration and is sensitive for detecting pleural fluid septations CT: * Used more for Underlying causes (esp in exudative) Pleural Fluid Analysis * Pleural fluid analysis requires a sample taken by aspiration or chest drain (USE USS to guide). * This helps establish the underlying cause by measuring the protein content, LDH, cell count, pH, glucose and microbiology testing. | can also see oesophogeal perforation ## Footnote Light's Criteria: pleural fluid protein divided by serum protein >0.5 = exudative

Answer 85

* **Conservative managemen**t may be appropriate as small effusions will resolve with treatment of the underlying cause. More significant effusions often need aspiration or drainage. * **Pleural aspiration** involves sticking a needle through the chest wall into the effusion and aspirating the fluid. Aspiration can temporarily relieve the pressure, but the effusion may recur, and further drainage may be required. * **Chest drain** can be used to drain the effusion and prevent it from recurring.

Answer 86

Empyema refers to an **infected pleural effusion.** Suspect an empyema in a patient with improving pneumonia but a new or ongoing fever. * Pleural aspiration shows pus, low pH, low glucose and high LDH. * if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed | Empyema is treated with a chest drain and antibiotics.

Answer 87

Accumulation of air in the pleural space - resulting in partial or complete collapse of lung. **Spontaneous Pneumothorax** - Primay (no disease) - Secondary (underlying disease) **Traumatic Pneumothorax** (result of trauma) **Iatrogenic Pneumothorax** (Complication of throcentesis, CV cathetar, ventilation- invasive and non, biopsy of lung) **Tension Pneumothorax** (severe pneumothorax resulting in respiratory distress and haemodynamic collapse) ## Footnote Primary Spontaneous: Tall, thin, young individuals. Rupture of subpleural blebs/bullae Secondary Spontaenous: COPD, Asthma, CF, Lung cancer, Marfans Syndrome.

Answer 88

* Pneumothorax caused by endometriosis within the thorax. * 3-6% of spontaneous pneumothoraces * occurring in menstruating women.

Answer 89

* Caused by Trauma * Air enters pleural space on **inspiration** * **Trauma forms parenchymal flap** - which prevents air from leaving during **expiration** by forming one way valve. * Rise in pressure causes shift of organs in mediastinum (trachea deviation) * This can lead to respiratory distress then cardioresp arrest | More dangerous as air enters but does not leave pleural space! ## Footnote Symptoms In tension pneumothorax: * respiratory distress * tracheal deviation away from the side of the pneumothorax * hypotension

Answer 90

Symptoms * Dyspnoea * Chest pain (pleuritic) Signs * Hyper-resonant lung percussion * Reduced breath sounds * Reduced Expansion * Tachypnoea * Tachycardia

Answer 91

* CXR: Diagnostic, There will be a line demarcating the edge of the lung where the lung markings end and the pneumothorax begins. * CT Thorax: can detect a pneumothorax that is too small to be seen on a chest x-ray. It can also be used to assess the size of the pneumothorax accurately. ## Footnote Measuring the size of the pneumothorax on a chest x-ray can be done according to the BTS guidelines (2010). This involves measuring horizontally from the lung edge to the inside of the chest wall at the level of the hilum.

Answer 92

**Primary**: * If rim <2cm + no dyspnoea: self limiting * if rim <2cm + symptoms: Aspiration * >2cm Rim - Chest drain. **Secondary**: * Rim >2cm + 50y+ + SOB -> chest drain * 1-2cm Rim: Aspiration * If fails -> Chest drain + O2 * <1cm Rim: resolve with O2 **Recurrent Pneumothoraces** * video-assisted thoracoscopic surgery (VATS) * for mechanical/chemical pleurodesis +/- bullectomy. ## Footnote Discharge Advice Smoking: Avoid smoking (risk is 10% more than normal non smoker) Flying: 1 week post chest xray you can fly Scuba diving: Complete ban unless patient's had bilateral surgical pleurectomy and has post-op CT to determine that and lung function.

Answer 93

* Hypersensitivity induced lung damage * Caused by immunune mediated tissue damage - **T3 Hypersensitivity** rxn * inhalation of organic particles like: Bird Breeders Lungs (avian proteins from dropping), Farmers lungs (saccharoppolyspara R from wet hay), Malt Workers Lung's (Aspergiuls), Mushroom Workers. | delayed hypersensitivity (type IV) is also thought to play a role

Answer 94

**Acute** (occurs 4-8 hrs after exposure) * dyspnoea * dry cough * fever **Chronic** (occurs weeks-months after exposure) * lethargy * dyspnoea * productive cough * anorexia and weight loss Investigations - Upper/midzone fibrosis (CXR) - High Lymphocyte count in Brochoalveolar lavage. - No Eosinophilla - IgG +ve when compared ## Footnote **Management** * avoid precipitating factors * oral glucocorticoids

Answer 95

* Allergy to Aspergilus Spores * Bronchoconstriction: Wheeze, Cough, Dyspnoea * Proximal **Bronchieactasis** * **Mislabled as asthma** * Bloods show **Eosinophila** * **RAST test +ve** * Raised IgE * Managed with oral glucocorticoids (prednislone)

Answer 96

* interstitial lung disease caused by Long term exposure to coal particles * Macrophages (usually involved in removing dust particles) begin to accumulate in the alveoli over time, which starts an immune response, causing damage to the lung tissue. * Dust exposure causes patients to develop round fibrotic masses * Avoid exposure to coal dust and other respiratory irritants (e.g. Smoking). Manage symptoms of chronic bronchitis ## Footnote *Pneumoconiosis = accumulation of dust in the lungs and the response of the bodily tissue to its presence, most commonly used in relation to coal worker’s pneumoconiosis.

Answer 97

* Autoimmune condition affecting URT, LRT and Kidneys * Epistaxis, sinusitis, nasal crusting, haemoptysis, dyspnoea, glomerulonephritis * Saddle shape nose deformity * cANCA +ve in 90% * pANCA +ve in 25% ## Footnote Management: - Steroids - Cyclophosphamide - Plasma Exchange - Median Survival 8-9Y

Answer 98

1. Pleural Plaques - Benign (ghosts on Xray) - no follow up required 2. Pleural Thickening 3. Asbestosis - SOB, Clubbing, End Insp Crackeles, Conservative management 4. Mesothelioma 5. Lung Cancer

Answer 99

* Day time somnolence (drowsiness) * Resp acidosis + HTN * Epworth Sleep Scale - Assesment * Sleep Studies - Diagnositic * Wt loss, CPAP - Management * DVLA to be indormed if excess daytime sleepiness

Answer 100

* Common postoperative complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions. * It should be suspected in the presentation of dyspnoea and hypoxaemia around 72 hours postoperatively | Alveoli deflation ## Footnote **Atelectasis is where a portion of the lung collapses due to under-ventilation** Management * positioning the patient upright * chest physiotherapy: breathing exercises

Answer 101

* hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis) * coal worker's pneumoconiosis/progressive massive fibrosis * silicosis * sarcoidosis * ankylosing spondylitis (rare) * histiocytosis * tuberculosis * radiation-induced pulmonary fibrosis (may develop following radiotherapy for breast or lung cancer, typically seen between 6 and 12 months following completion of radiotherapy course)

Answer 102

* idiopathic pulmonary fibrosis * most connective tissue disorders (except ankylosing spondylitis) e.g. SLE * drug-induced: amiodarone, bleomycin, methotrexate * asbestosis ## Footnote HEARTS (upper): - Histiocytosis - Extrinsic allergic alveolitis - Ankylosing spondylitis - Radiation - Tuberculosis - Sarcoidosis & silicosis RAID (lower): - Rheumatoid arthritis - Asbestosis - Idiopathic - Drugs (amiodarone, cyclophosphamide, methotrexate, bleomycin, nitrofurantoin, hydralazine)

Answer 103

* Fibrosing lung disease coz of inhalation of crystalline silicon dioxide (silica) * Can lead to TB - silica is toxic to macrophages) * EGG shell calcification of hilar lymph nodes on CXR * Upper zone fibrosis

Answer 104

* Type 1 respiratory failure affects 1 value (PaO2 ↓) * Type 2 respiratory failure affects 2 values (PaO2 ↓ and PaCO2 ↑) ## Footnote Type 1: VQ Mismatches: Pneumonia, Pulmonary Oedema, Pulmonary Embolism Type 2: Hypoventilation: Exacerbation of COPD, Opiate overdose/sedation, Rib fractures, Guillain-Barré syndrome