Respiratory Flashcards
1
Q
Define asthma
A
Chronic inflammatory airway disease characterised by reversible, intermittent airway obstruction and hyper-reactivity, leading to variable airway obstruction
2
Q
What type of inflammation is asthma
A
Type 2
3
Q
What are the 2 major factors in the pathophysiology of asthma
A
Inflammation
Airway hyper-responsiveness
4
Q
What parts of the airway are affected by asthma
A
Large airways
Small airway with diameters < 2 micrometres
5
Q
Describe the pathophysiology of asthma
A
Initial trigger leads to release of inflammatory mediators
Inflammatory reaction = T helper type 2 lymphocytic response.
Inflammation results in increased bronchial hyper-responsiveness and recurrent episodes of wheezing, breathlessness, chest tightness and coughing
6
Q
What cell is involved in near fatal exacerbations of asthma
A
Neutrophils
7
Q
What type of condition is asthma
A
Atopic
Includes - eczema, hay fever and food allergies
If have 1 more likely to have others
8
Q
Name the risk factors of asthma
A
Family history
Allergens/irritants
Atopic disease history
Cigarette smoking or vaping
Respiratory viral infections in early life
Nasal polyps
Low socioeconomic class
9
Q
Name the clinical features of asthma
A
Symptoms = episodic
Diurnal variability - worse at night
SOB
Chest tightness
Dry cough
Wheeze
10
Q
What is a sign of life threatening asthma
A
Silent chest
Wheeze disappears when the airway gets so tight there is no entry
11
Q
Name 6 triggers of asthma
A
Infection
Night-time or early morning
Exercise
Animals
Cold, damp or dusty air
Strong emotions
12
Q
Name the investigations for asthma
A
Spirometry
Reversibility testing
Fractional exhaled nitric oxide
Peak flow
Direct bronchial challenge test
13
Q
What would a positive test for asthma be in a peak flow
A
Variability > 20%
14
Q
What type of lung disease is asthma
A
Obstructive
FEV1: FVC < 70%
15
Q
Describe the route of pharmacological management in asthama
A
- Offer SABA reliever
- Offer low dose ICS (1st line maintanance therapy
- If uncontrolled on low dose ICE add leukotriene receptor
- Add LABA in combination with ICS
- MART therapy
16
Q
Describe the role of beta-2 adrenergic receptor agonists in asthma
A
Bronchodilators
Adrenalin acts on smooth muscle of the airways cause relaxation
Short acting and long acting
17
Q
Describe the role of inhaled corticosteroids in asthma
A
Reduce inflammation and reactivity of the airways
Maintain or prevent symptoms
18
Q
Describe the role of long acting muscarinic antagonists
A
Block Ach receptors
Dilates the bronchioles and reverses bronchoconstriction
19
Q
Describe the role of leukotrienes receptor antagonists in asthma
A
Block effect of leukotrienes
These are produced by the immune system - can cause inflammation, bronchoconstriction and mucus secretion in airways
20
Q
Describe the role of theophylline in asthma
A
Relaxes bronchial smooth muscles and reduces inflammation.
Narrow therapeutic window
21
Q
Describe MART in asthma
A
Combination of inhaler containing corticosteroids and fast and long acting beta agonist
Replaces all inhalers
Can be used as prevented and reliver
22
Q
Name the additional management in asthma
A
Individual written asthma self-management plan
Yearly flu jab
Yearly asthma review once stable
Regular exercise
Avoid smoking
Avoiding triggers where appropriate
23
Q
What are the features of acute exacerbation of asthma
A
Progressively SOB
Use of accessory muscles
Tachypnoea
Symmetrical expiratory wheeze on auscultation
Chest sound ‘tight’ on auscultation
24
Q
What would arterial blood gas show in acute exacerbation of asthma
A
Respiratory alkalosis
25
Name the differential diagnosis of asthma
COPD
Chronic rhinosinusitis
Dysfunctional breathing
Vocal cord dysfunction
Bronchiectasis
Congestive heart failure
Cystic fibrosis
26
Define bronchiectasis
Abnormal dilation of bronchi due to the destruction of the elastic and muscular components of the bronchial wall
27
Describe the pathophysiology of bronchiectasis
Involves permanent dilation of the bronchi
Sputum collects and organisms grow in the wide tube
Results - chronic cough, continuous sputum production and recurrent infections
28
Name the causes of bronchiectasis
Idiopathic
Pneumonia
Whooping cough
TB
Alpha-1 antitrypsin deficiency
Connective tissue disorders
Cystic fibrosis
Yellow nail syndrome
29
Name 5 risk factors of bronchiectasis
Cystic fibrosis
Host immunodeficiency
Previous infections
Congenital disorders of the bronchial airway
Primary ciliary dyskinesia
30
Name 4 symptoms of bronchiectasis
SOB
Chronic productive cough
Recurrent chest infections
Weight loss
31
Name the signs of bronchiectasis
Weight loss
Finger clubbing
Signs of cor pulmonale
Scattered crackles
throughout chest that change or clear with coughing
Scattered wheeze and squeaks
32
Name the investigations of bronchiectasis
Sputum culture
Chest x-ray
High-resolution CT
33
What is the gold standard for diagnosis of bronchiectasis
High-resolution CT
34
What would be seen on a chest x-ray of bronchiectasis
Tram-track opacities
Ring shadows
35
Describe the general management of bronchiectasis
Vaccines
Respiratory physiotherapy
Long-term antibiotics
Inhaled colistin
Long-acting bronchodilators
Long-term oxygen therapy
Surgical lung resection
Lung transplant
36
Describe the treatment of infective exacerbations of bronchiectasis
Sputum culture - before antibiotics
Extended course of antibiotics - usually 7-14 days
Ciprofloxacin
37
Name 4 differential diagnosis of bronchiectasis
COPD
Asthma
Pneumonia
Chronic sinusitis
38
Define COPD
Heterogeneous lung disease state characterised by chronic respiratory symptoms and airflow limitation that is not fully reversible
39
What does COPD encompass
Emphysema, bronchiolitis, chronic bronchitis
40
Define chronic bronchitis
Long-term symptoms of cough and sputum production due to inflammation in the bronchi
41
Define emphysema
Involves damage and dilation of alveolar sacs and alveoli decreasing surface area for gas exchange
42
What is the hallmark of COPD
Chronic inflammation that affects the central and peripheral airways, lung parenchyma and alveoli, and pulmonary vasculature
43
Name the main components of the pathophysiology of COPD
Narrowing and remodelling of airways
Increased number of goblet cells
Enlargement of mucus secreting glands of the central airways
Alveolar loss
Vascular bed changes leading to pulmonary hypertension
44
What is the main cause of COPD and why?
Smoking
Inflammatory response of the lung to noxious particles and gases
Cilia dysfunction and oxidative injury
45
Name 4 causes of COPD
Smoking
Air pollution
Indoor burning of biomass fuels
Occupational exposure to dust, chemical agents and fumes
46
Name 4 risk factors of COPD
Cigarette smoking
Advanced age
Genetic factors
Lung growth and development
47
Describe the typical presentation of COPD
SOB
Cough
Sputum production
Wheeze
Recurrent respiratory infections - particularly in winter
48
Name the investigations of COPD
Spirometry
FEV1
MRC Dyspnoea Scale
49
Describe spirometry results in COPD
Obstructive
FEV1: FVC ratio < 70%
Little of no response to reversibility testing with beta-2 agonists
50
How is COPD diagnosed
Clinical presentation + spirometry
51
How is the severity of COPD graded
Using FEV1
Stage 1 mild to stage 4
52
What is the 1st line medical management of COPD
Short acting bea-2 agonists
Short acting muscarinic receptors - ipratropium bromide
53
What would be seen on an arterial blood gas of a COPD exacerbation
Respiratory acidosis
54
What would be the 1st line management of an acute COPD exacerbation
Regular inhalers or nebulisers
Steroids
Antibiotics
55
How is asthma differentiated from COPD
COPD - airway obstruction is minimally reversible with bronchodilators
56
Name 3 clinical features which are not present in COPD which should make you think of a differential diagnosis
Clubbing
Haemoptysis
Chest pain
57
Name 4 differential diagnosis for COPD
Asthma
Lung cancer
Pulmonary fibrosis
Heart failure
58
Name the complications of COPD
Cor pulmonale
Lung cancer
Recurrent pneumonia
Depression
Pneumothorax
Respiratory failure
Anaemia
Polycythaemia
59
Define cystic fibrosis
Severely life shortening genetic disease resulting from abnormalities in the cystic fibrosis transmembrane conductance regulator - a chloride channel found in the cells in the lining of the lungs, intestines, pancreatic duct, sweat glands and reproductive organs
60
Describe the pathophysiology of cystic fibrosis
Abnormal chloride channel transporter by the epithelial cells result in thick, sticky secretions
61
What are the key consequences off the pathophysiology of cystic fibrosis
Lack of digestive enzymes (pancreas)
Low airway clearance = infections
Male infertility (absence of vas deferens)
62
Name 2 common colonisers of the lungs in cystic fibrosis
Staphylococcus aureus
Pseudomonas aeruginosa
63
Describe the cause of cystic fibrosis
Autosomal recessive genetic condition.
Caused by genetic mutation of the cystic fibrosis transmembrane conductance regulatory gene on chromosome 7
Most common variant = F508del
Encodes for chloride channels in the apical membrane of epithelial cells
64
Name 3 risk factors of cystic fibrosis
Family history of CSF
Known carrier status of both parents
Ethnicity - white
65
Describe the most common 1st presentation of cystic fibrosis
Meconium ileus
66
Name the symptoms of cystic fibrosis
Chronic cough with sputum production
Recurrent resp infections
Loose, greasy stools - steatorrhea
Abdominal pain and bloating
Failure to thrive
67
Name 5 signs of cystic fibrosis
Low weight or height on growth charts
Nasal polyps
Finger clubbing
Crackles and wheezes on auscultations
Abdominal dissention
68
What is the gold standard diagnostic investigation for cystic fibrosis
Sweat test
69
What are the 3 methods of diagnosis for cystic fibrosis
New-born blood spot screening
Sweat test
Genetic testing for CFTR gene
70
What is the general management of cystic fibrosis divided into
For respiratory disease
For GI disease
71
What is the general treatment of cystic fibrosis in respiratory disease
Mucus thinners
Airway clearance
Antibiotics
72
What is the general management of cystic fibrosis GI disease
Aim to help support growth and nutrition
Supplement pancreatic enzymes
Calorie support
Fat soluble vitamins
73
Name 5 differential diagnosis of cystic fibrosis
Asthma
GORD
Chronic aspiration
Failure to thrive
Coeliac disease
74
Describe the monitoring of cystic fibrosis
Follow up every 6 months
Require regular monitoring of sputum for colonisation
Monitoring/screening for diabetes, osteoporosis, vitamin D deficiency and liver failure
75
Describe the prognosis of cystic fibrosis
Life expectancy = 47 years
90% = pancreatic insufficiency
50% = diabetes
30% = liver disease
Most males infertile
76
Name 6 complications of cystic fibrosis
Chronic respiratory failure
Sleep disturbances
Obstructive sleep apnoea
Delayed puberty
Chronic rhinosinusitis
Failure to thrive
77
Define pleural effusion
Collection fluid in the pleural space.
Categorised into:
- exudative = high protein content (> 30 g/L)
- transudative = low protein content (< 30 g/L)
78
Describe the pathophysiology of pleural effusion
Primary reason = imbalance between the fluid production and fluid removal in the pleural space.
Fluid is remove by lymphatics in partial pleura
Balance is disrupted by:
- local factors (exudate)
- transudate - often multifactorial
79
Name the exudative causes of pleural effusion
Related to inflammation - inflammation results in protein leaking out of the tissues into the pleural space
Cancer
Infection
Rheumatoid arthiritis
80
Name the transudative causes of pleural effusion
Relate to fluid moving across or shifting into the pleural space
Congestive cardiac failure
Hypalbuminaemia
Hypothyroidism
Meigs syndrome
81
Name 4 risk factors of pleural effusion
Congestive heart failure
Pneumonia
Malignancy
Recent coronary artery bypass graft surgery
82
Describe the clinical features of pleural effusion
SOB
Examination findings
- dullness to percussion over the effusion
- Reduced breath sounds
- Tracheal deviation away from the effusion (very large effusions)
83
Name the investigations of a pleural effusion
Light's criteria
X-ray
Imaging
Pleural fluid analysis
84
Describe lights criteria
Used to establish exudative effusion using protein or lactate dehydrogenase
85
What would be seen on an x-ray of pleural effusion
Blunting of the costophrenic angle
Fluid in the lung fissures
Larger effusions will have a meniscus
Tracheal and mediastinal deviation away from the effusion
86
Describe pleural fluid analysis as an investigation of pleural effusion
Sample taken by aspiration of chest drain
Helps establish underlying cause
Measures - Protein content, LDH, cell count, glucose and microbiology testing
87
Describe the management of pleural effusion
Diagnosing + treatment of underlying cause = mainstay
Conservative management
Pleural aspiration
Chest drain
88
Name 5 differential diagnosis of pleural effusion
Pleural thickening
Pulmonary collapse and consolidation
Elevated hemidiaphragm
Pleural tumours
Covid-19
89
Name a complication of pleural effusion
Empyema = infected pleural effusion
Patient with improving pneumonia but new or ongoing fever
90
What does pleural aspiration show in empyema
How is it treated
Pus, low pH, low glucose and high LDH
Chest drain and antibiotics
91
When would a pleural effusion be likely to reoccur
If due to heart failure, cirrhosis or malignancy
92
Define pneumonia
Infection of the lung tissue, causing inflammation in the alveolar space
93
What is the general rule of bacterial and viral infections in the lungs
Lower down the respiratory tract, the higher the probability of bacterial infection, opposed to viral
Upper = generally viral
94
How can pneumonia be classified
Community-acquired pneumonia = develops in the community
Hospital-acquired pneumonia = develops after > 48 hours in
hospital
Ventilator-acquired pneumonia = develops intubated patients in ICU
95
Define aspiration pneumonia
Infection develops due to aspiration of food or fluids, usually in patients with impaired swallowing.
Associated with anaerobic bacteria
96
Describe atypical pneumonia
Caused by an organism that cannot be cultured in a normal way or detected using gram stain.
97
Name 5 causes of atypical pneumonia
Legions of psittaci MCQs
Lesions - legionella pneumophilia
Psittaci - chlamydia penumophillia
M - Mycoplasma pneumoniae
C - Chlamydophila pneumoniae
Qs - Q fever - Coxiella Brunetti
98
Describe legionella pneumophilia as a cause of atypical pneumonia
Inhaling infected water
Caused of SIAH
initial screening = urine antigen
99
Describe mycoplasma pneumonia as a cause of atypical pneumonia
Milder pneumonia
Rash = erythema multiforme
Can cause neurological symptoms
100
Describe Q fever as a cause of atypical pneumonia
Linked to exposure to bodily fluids or animals
101
Describe chlamydia psittaci as a cause of atypical pneumonia
Typically contracted from contact with infected bodies
102
What are the two typical bacterial causes of pneumonia
Streptococcus pneumoniae
Haemophilus
103
What is the most common cause of pneumonia in patients with HIV
Pneumocystis jirovecii
Fungal pneumonia
104
How is pneumocystis pneumonia treated
Co-trimoxazole
105
Name the risk factors of community acquired pneumonia
Age > 65 years
Residence in healthcare setting
COPD
Smoking
Alcohol abuse
Poor oral hygiene
106
Name the risk factors for hospital acquired pneumonia
Poor infection control/hygiene
Intubation and mechanical ventilation
Multidrug resistant bacteria
Aspiration
107
Name the presenting symptoms of pneumonia
Cough
Sputum production
SOB
Fever
Haemoptysis
Pleuritic chest pain
Delirium
108
Name 3 characteristic chest signs of pneumonia
Bronchial breath sounds
Focal coarse crackles
Dullness to percussion
109
Name the investigations of pneumonia
Community (not necessarily need investigations)
Chest x-ray
FBC
Renal profile
C-reactive protein
Sputum cultures
Blood cultures
Pneumococcal and Legionella urinary antigen tests
110
What is roughly proportional to the severity of infection in pneumonia
White blood cells + CRP
111
What assessment is used to measure the severity of pneumonia
CRB-65 or CURB-65 (in hospital)
112
Describe CURB-65
Predicts mortality from pneumonia
Confusion
Urea > 7 mmol/L
Respiratory rate > (or equal to) 30
Blood pressure < 90 systolic or < (or equal to) 60 diastolic
Age > (or equal to) 65
113
Describe the management of mild community acquired pneumonia
5 day oral antibiotics
- amoxicillin
- doxycycline
- clarithromycin
114
Describe the management of moderate or severe pneumonia
IV antibiotics
Stepped down to oral
Respiratory support
115
Name 5 differential diagnosis of pneumonia
COVID-19
Cardiogenic pulmonary oedema
ARD
Pleural effusion
Pulmonary embolus
116
Name 6 complications of pneumonia
Sepsis
ARDS
Pleural effusion
Empyema
Lung abscess
Death
117
Define TB
Infectious disease caused by mycobacterium tuberculosis
118
Describe the pathogenesis of TB
Inhalation of aerosolised nuclei
Mycobacterium is engulfed by alveolar macrophages - survives and multiplies within
Proliferating bacilli kill macrophages and are released.
Event produces a response in the immune system
119
Describe the disease course of TB
Immediate clearance of bacteria - most cases
Primary active TB - active infection after exposure
Latent TB - presence of bacteria without being symptomatic or contagious
Secondary TB - reactivation of latent TB to active infection
120
Describe latent TB
Present when the immune system encapsulates the bacteria and stops the progression of the disease
No symptoms - cannot spread
Can reactivate - most do not go onto develop the infection
121
Describe the cause of TB
By mycobacterium TB - bacillus
Hard to culture in the lab
Must be stained using Zeihl-Neelsen stain
122
What bacteria is 'acid fast bacilli' that stain red with 'Zeihl-Neelsen staining'
Mycobacterium tuberculosis
123
What are multidrug resistant TB
Strains that are resistant to more than 1 TB drug
Makes them difficult to treat
124
Name the risk factors of TB
Exposure to infection
Birth in an endemic country
HIV infection
Immunosuppressive medicines
Silicosis
Apical fibrosis
Malnutrition, homelessness, drug users, smokers and alcoholics
125
Describe the clinical features of TB
Chronic, gradually worsening symptoms
Cough
Haemoptysis
Lethargy
Fever/night sweats
Weight loss
Lymphadenopathy
Erythema nodosum
Spinal pain
126
What is erythema nodosum
Tender, red nodules on shins caused by inflammation of the subcutaneous fat
127
Name the investigation of TB
Mantoux test
Interferon-gamma release assay
To show an immune response to TB caused by previous infection, latent TB or active TB
128
What is used to support a diagnosis of TB
Chest x-ray
Cultures
NAAT
129
What does pulmonary TB look like on a chest x-ray
Patchy consolidation
Pleural effusions
Hilar lymphadenopathy
130
What does reactive TB show on a chest x-ray
Patchy or nodular consolidation with cavitation (gas filled spaces) - typically in upper zones
131
What does disseminated millary TB look like on a chest x-ray
Millet seeds uniformly distributed across the lung fields
132
Describe the management of latent TB
Either:
- Isoniazid + rifampicin for 3 months
- Isoniazid for 6 months
133
Describe the management of active TB
RIPE
Rifampicin - 6 months
Isoniazid - 6 months
Pyrazinamide - 2 months
Ethambutol - 2 months
134
What is isoniazid co-prescribed with
Pyridoxine (vitamin B6) - prevent peripheral neuropathy
135
Describe the further management for TB
Testing for other infectious disease
Testing contacts
Notifying UK health security agency of suspected cases
Isolating patients with active TB
136
Name the differential diagnosis of TB
Covid-19
Community-acquired pneumonia
Lung cancer
Non-TB mycobacteria
Fungal infection
137
Describe the side effects of rifampicin
Red/orange discolouration of secretions
Potent inducer of C450 enzymes - can reduce effects of drugs metabolised by them e.g. combined contraceptive pill
138
Describe the side effects of isoniazid
Can cause peripheral neuropathy
139
Describe the side effects of pyrazinamide
Can cause hyperuricaemia
Results in gout and kidney stones
140
Describe the side effects of ethambutol
Can cause colour blindness and reduced visual acuity
141
Describe the prognosis of TB
Mortality 50% without treatment
Treated - do well
Risk factors for death
142
Define pneumothorax
Occurs when air enters the pleural space, separating the lung from the chest wall
143
Describe the pathophysiology of pneumothorax
Communication develops and gases will follow the pressure gradient and flow into the pleural space
Flow continues until no pressure gradient
Result = enlarged cavity, lung becomes smaller when a pneumothorax develops
144
Define a tension pneumothorax
Occurs when the intrapleural exceeds atmospheric pressure
Caused by trauma to the chest wall that creates a one-way valve that lets air in but not out of the pleural space
145
Describe the pathophysiology of a tension pneumothorax
On-way valve- air is drawn into the pleural space during inspiration
During expiration air is trapped.
More breath in = more air drawn into the pleural space and cannot escape
146
Describe how tension pneumothorax can be dangerous
Pressure inside the thorax to push the mediastinum across
Kink the big vessels in the mediastinum and cause cardiorespiratory arrest
147
Name the causes of pneumothorax
Spontaneous
Trauma
Iatrogenic - lung biopsy, mechanical ventilation or central line insertion
Lung pathologies - infection, asthma or COPD
148
Who would get a primary spontaneous pneumothorax
Young people without known respiratory illness
149
Who would get secondary spontaneous pneumothorax
Patients with pre-existing pulmonary diseases
150
What is the immediate treatment of a tension pneumothorax
Decompression
151
Name the risk factors of pneumothorax
Cigarette smoking
Family history
Tall and slender body build
Age < 40
Recent invasive medical procedure
Chest trauma
Acute severe asthma
COPD
TB
Cystic fibrosis
152
Describe the typical patient of a pneumothorax
Tall, thin young man presenting with sudden breathlessness and pleuritic chest pain, possibly whilst playing sport
153
Describe the clinical features of a pneumothorax
SOB
Pleuritic chest pain
Dyspnoea
154
Describe the clinical symptoms of a tension pneumothorax
Distressed
Rapid laboured respirations
Cyanosis
Profuse diaphoresis
Tachycardia
155
Name 5 signs of a tension pneumothorax
Tracheal deviation away from the side of the pneumothorax
Reduced air entry on the affected side
Increased resonance to percussion on the affected side
Tachycardia
Hypotension
156
What is the 1st line investigation of a pneumothorax
Erect chest x-ray
157
What would be seen on a erect chest x-ray in a pneumothorax
Areas between the lung and chest walls with no lung markings
Line demarcating the edge of the lung
Measuring the size
158
What is the alterative investigation for a pneumothorax
CT thorax
Detect when too small to be seen on a chest x-ray
Can be used to assess size correctly
159
Describe how management is decided for a pneumothorax
No treatment
- no SOB
- <2cm rim air on chest x-ray
- follow up 2-4 weeks
Treatment
- SOB
- >2cm rim of air on chest x-ray
160
What is the main treatment of a pneumothorax
Chest drain
161
Describe a chest drain in a pneumothorax
For - unstable, bilateral or secondary
In triangle of safety - avoid the neurovascular bundle.
repeat x-ray
162
Describe the triangle of safety
5th intercostal space
Midaxillary line
Anterior axillary line
163
Why would surgery be done in a pneumothorax
Chest drain fails to correct
Persistent air leak in drain
Reoccurs
164
What is the surgery that can be completed on a pneumothorax
Video-assisted thoracoscopic surgery (VATS)
165
Describe the management of a pneumothorax
Insert a large bore cannula into the 2nd intercostal space in the midclavicular line
If suspected - do not wait for investigations
Chest drain afterwards
166
Name differential diagnosis of pneumothorax
Asthma/COPD acute exacerbation
Pulmonary embolism
Myocardial ischemia
Pleural effusion
Fibrosing lung disease
167
Name complications of chest drain
Air leaks around the drain site
Surgical emphysema
168
Describe empyema
Presence of pus in the pleural space
169
Describe the pathophysiology of empyema
1. Exudative stage - sterile fluid accumulates
2. Fibrinopurulent stage - commences with bacterial invasion in pleural space.
3. Organisational stage - if infection progress - empyema becomes organised
170
Name the main cause of empyema
Follows bacterial pneumonia
171
Name 5 risk factors of empyema
Pneumonia
Iatrogenic interventions in the pleural space
Thoracic trauma
Immunocompromised state
Comorbid lung disease
172
Describe the presentation of empyema
Patients with improving pneumonia but a new or ongoing fever
173
Name 4 features which can be seen on a physical examination of empyema
Dullness to percussion on the affected area
Egophonia
Increased palpable fremitus
Fine crackles
174
Name a scoring system of empyema
RAPID
175
Describe the RAPID scoring system of empyema
Renal - kidney function
Age
Presence of albescence of pus
Hospital acquired vs. community-acquired infection
Diet - albumin levels
Score 5 or more = poor outcomes
176
Name the investigations of empyema
Chest x-ray
Ultrasound
CT scan
Pleural aspiration
177
Name 4 findings on an aspiration of empyema
Pus
Low pH
Low glucose
High LDH
178
Name the management of empyema
Chest drain
Antibiotics
Surgery
179
Name the differential diagnosis of empyema
Pneumonia
Lung abscess
Malignant pleural effusion
Oesophageal rupture
Haemothorax
179
Describe the antibiotics of empyema
Empirical IV antibiotics
Penicillin's
OR
Penicillin's combined with beta-lactamase, cephalosporins and metronidazole
180
Name 3 complications of empyema
Septic shock
Respiratory failure
Chest drain complications
181
Describe the prognosis of empyema
Approx. 24% need surgery
Mortality 15-20%
182
Define croup
Common respiratory disease of childhood, characterised by the sudden onset of a seal-like barky cough, often accompanied by stridor, voice hoarseness and respiratory distress
183
Describe the pathophysiology of croup
Upper airway obstruction due to generalised inflammation and oedema of the airways
Cellular level - progresses to necrosis and shedding of epithelium
Narrowed subglottic region
184
What is the common cause of croup
Viral infection - parainfluenza virus type 1 or 3
185
Name the risk factors of croup
Age 6 months to 6 years
Weak - male sex, prior intubation
186
Name the clinical features of croup
Upper airway obstruction
Seal-like barky cough
Stridor
Voice hoarseness
Respiratory distress
187
Name the investigation of croup
Clinical investigation
188
What is the 1st line management of all causes of croup
Oral corticosteroids - dexamethasone
189
In moderate to severe croup what would be given in addition to the 1st line treatment
1st line = dexamethasone
+ nebulised epinephrine (adrenaline)
190
Name the differential diagnosis of croup
Bacterial tracheitis
Epiglottis
Foreign body in the upper airway
Retropharyngeal abscess
Allergic reaction
191
Name the complications of croup
If upper airway obstruction worsens - respiratory failure can result
Asynchronous chest
Abdominal wall motion
Fatigue
Hypoxia
Hypercapnia
192
Define hypersensitivity pneumonitis
Inflammation of the alveoli and distal bronchioles caused by an immune response to inhaled allergens
193
Describe the pathophysiology of hypersensitivity pneumonitis
Result from non-IgE mediated immunological inflammation
Caused by repeated inhalation of non-repeated protein
Inflammation in the alveoli and distal bronchioles
194
Name 2 main causes of hypersensitivity pneumonitis
Bacteria - actinomycetes
Animal proteins - avian protein
195
Name 4 causes of hypersensitivity pneumonitis
Bacteria
Animal proteins
Fungi
Reactive chemicals
196
Name risk factors of hypersensitivity pneumonitis
Smoking
Viral infection
Exposure to..
197
Name clinical features of hypersensitivity pneumonitis
Fever
Tachypnoea
Dyspnoea
Restrictive function tests
Reduced diffusing capacity to carbon monoxide
198
What would be seen in the later stages of hypersensitivity pneumonitis
Malaise
Weight loss
Dyspnoea
Cough
199
Name the investigations of hypersensitivity pneumonitis
Chest x-ray
Chest CT
Serum antigen specific IgG or IgA
Pulmonary function test
200
What would be seen on a chest x-ray of hypersensitivity pneumonitis
Infiltrates
Nodular or patchy fibrosis
201
Describe the management of hypersensitivity pneumonitis
1st line - avoidance of antigen
Smoking cessation, pulmonary rehabilitation, supplemental oxygen
Corticosteroids
202
Name the differential diagnosis of hypersensitivity pneumonitis
Viral pneumonia
Sarcoidosis
Idiopathic pulmonary fibrosis
203
Name 3 complications of hypersensitivity pneumonitis
Progressive deterioration in the lung function
Hypoxaemia
Death
204
Describe the histology of lung cancer
Small-cell (20%)
Non-small cell (80%)
- adenocarcinoma
- squamous cell carcinoma
- large-cell carcinoma
- other types
205
Describe the epidemiology of lung cancer
3rd most common cancer
80% thought to be preventable
206
Name the main risk factor/cause of cancer
Smoking
Other - radon gas
207
Describe the general clinical features of lung cancer
SOB
Cough
Haemoptysis
Finger clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy
208
What is generally the 1st sign of lung cancer found on examination
Lymphadenopathy - supraclavicular nodes
209
Name the extrapulmonary manifestations of lung cancer
Recurrent nerve palsy
Phrenic nerve palsy
Superior vena cava obstruction
Horner's syndrome
Syndrome of inappropriate ADH
Cushings syndrome
Hypercalcaemia
Limbic encephalitis
Lambert-Eaton myasthenic syndrome
210
Describe Horner's syndrome
Triad
- ptosis
- anhidrosis
- miosis
Can be caused by a Pancoast tumour (tumour pulmonary apex) - pressing on sympathetic ganglion
211
Describe limbic encephalitis
Paraneoplastic syndrome - small cell lung cancer caused immune system to make antibodies to tissues in the brain causing inflammation in these areas
Anti-Hu antibodies
212
Describe lambert-eaton myasthenic syndrome
Caused by antibodies against small-cell lung cancer cells
Antibodies target and damage voltage gated calcium channel site on presynaptic terminals in motor neurones
Leads to weakness particularly in proximal muscles
213
Name the 1st line investigation of lung cancer
Chest x-ray
214
What findings on a chest x-ray would be suggestive of lung cancer
Hilar enlargement
Peripheral opacity
Pleural effusion
Collapse
215
Name investigations of lung cancer
Chest x-ray
Staging CT scan - contrast
PET-CT
EBUS
Histological diagnosis
216
Describe bronchoscopy with endobronchial ultrasound (EBUS) as an investigation of lung cancer
Allows detailed assessment of the tumour and ultrasound guided biopsy
217
Describe the referral criteria for lung cancer
Offer chest x-ray (2 weeks) to patients over 40 with 5 symptoms or smoking status with symptoms
218
What are the surgical options of lung cancer
Segmentectomy or wedge resection
Lobectomy
Pneumonectomy
219
Name 5 differential diagnosis of lung cancer
Pneumonia/bronchitis
Carcinoid tumour
Infectious granuloma
Sarcoidosis
Rheumatoid arthritis
220
Define small-cell lung cancer
Malignant epithelial tumour arising from cells lining the lower respiratory tract
221
Describe the pathophysiology of small-cell lung cancer
Cells contain neurosecretory granules that release neuroendocrine hormones.
Tend to arise in the central lung with mediastinal involvement
Aggressive malignancy
222
Name 3 risk factors of small-cell lung cancer
Cigarette smoking
Environmental tobacco exposure
Radon gas exposure
223
What extra pulmonary symptoms can be seen in small-cell lung cancer
Syndrome of inappropriate ADH (SIADH)
Cushing's syndrome
Limbic encephalitis
Lambert-Eaton myasthenic syndrome
224
Describe the treatment of small-cell lung cancer
Localised = chemotherapy + radiotherapy
Extensive = chemotherapy + immunotherapy
Surgery
Palliative radiotherapy
225
What is the prognosis of small-cell lung cancer
Generally worse than non-small cell lung cancer
226
Define mesothelioma
Aggressive epithelial neoplasm arising from the lining of the lung, abdomen, pericardium or tunica vaginalis
227
Describe the pathophysiology of mesothelioma
Exposure of asbestos fibres = recruitment and activation of alveolar macrophages and neutrophils
Chronic inflammation and oxidative stress may culminate in DNA damage, alterations in gene expression and eventual malignant transformation
228
Describe the epidemiology of mesothelioma
20-40 year latent period between exposure and development
6-9th decade of life
Rare
229
Name the causes of mesothelioma
One of few cancers related directly between exposure and development
Asbestos
230
Name the clinical features of mesothelioma
Shortness of breath
Chest pain
Unilateral pleural effusion and pleural thickening
231
Describe the treatment of mesothelioma
Operable
- trimodal therapy
- with chemotherapy, surgery, and hemi thoracic radiotherapy
Inoperable
- chemotherapy or immune checkpoint inhibitor therapy
232
What is the prognosis of mesothelioma
Poor
233
Define non-small cell cancer
Compromises of a group of malignant epithelial tumours arising from the cells lining the lower respiratory tract
234
Name 5 risk factors of non-small cell lung cancer
Cigarette smoking
Environmental tobacco exposure
COPD
Family history
Radon gas exposure
235
Name 5 clinical features of non-small lung cancer
Cough
Chest pain
Haemoptysis
Dyspnea
Weight loss
236
What is the 1st line treatment for non-small cell lung cancer
Surgery
When isolated to a single area
237
Describe the treatment of non-small cell lung cancer
1st line = surgery
Radiotherapy
Chemotherapy - later stages (palliative)
238
Describe adenocarcinoma
Most common overall - including nonsmokers, young adults and women
Begins in glands of alveoli, usually in outer part of lung
Typically slow growing
239
Describe large cell lung carcinoma
Least common
Begins in large cells found anywhere in the lungs, but mostly in the outer part
Typically fast growing
240
Describe squamous cell carcinoma
2nd most common overall - most common in smokers
Begins in squamous cells in the bronchi - usually in centre of lungs
Typically slow growing
241
Define otitis media
An infection in the middle ear
242
Describe the pathophysiology of otitis media
Middle ear - space between tympanic membrane (ear drum) and inner ear
Bacteria enter from the back of the throat through the eustachian tube
Bacterial infection often preceded by viral respiratory infection
243
What is the most common cause of otitis media
Streptococcus pneumonia (also causes rhinosinusitis and tonsilitis)
244
Name 4 causes of otitis media
1st = streptococcus pneumonia
Haemophilus influenza
Moraxella catarrhalis
Staphylococcus aureus
245
Name the risk factors of otitis media
Childcare attendance
Older siblings
Young age
Family history
246
Name the clinical features of otitis media
Ear pain and reduced hearing (affected ear)
General symptoms of upper airway infection
May affect vestibular system or tympanic membrane
247
If otitis media affects the vestibular system what would the clinical features be
Balance issues
Vertigo
248
If otitis media affects the tympanic membrane what would the clinical features be
Discharge from the ear
249
Name the investigation of otitis media
Otoscope
250
Describe otoscope investigation of otitis media
Visualise tympanic membrane
Bulging red, inflamed looking membrane
Bulging, opacified tympanic membrane with an attenuated light reflex
May be discharge in the ear and a hole in the tympanic membrane
251
Describe the management of otitis media
Antibiotics - 1st line - amoxicillin 5 days
Simple analgesia
252
Name 4 differential diagnosis of otitis media
Otitis media with effusion
Myringitis
Mastoiditis
Cholesteatoma
253
Name the possible complications of otitis media
Hearing loss - temporary
Perforated eardrum
Recurrent infection
Rare
- mastoiditis
- abscess
254
Define sinusitis
Inflammation of the paranasal sinuses in the face.
Usually accompanied by inflammation of the nasal cavity (rhinosinusitis)
255
Describe the pathophysiology of sinusitis
Blockage of ostia prevents drainage of the sinuses
256
Name the causes of sinusitis
< 10 days - viral
> 10 days - bacterial
Infection
Allergies
Obstruction of drainage
Smoking
257
Name 3 risk factors of sinusitis
Asthma - increases risk
Viral upper respiratory tract infection
Allergic rhinitis
258
Describe the clinical features of sinusitis
Recent viral upper respiratory tract infection
Nasal congestion, discharge
Facial pain, headache, pressure, swelling
Loss of smell
259
Describe the investigations of sinusitis
Most cases = no investigations
If continue
- nasal endoscopy
- CT scan
260
Describe the management of acute sinusitis
Antibiotics (after 10 days)
High dose steroid nasal spray 14 days
261
Describe the management for chronic sinusitis
Saline nasal irrigation
Steroid nasal sprays or drops
Functional endoscopic sinus surgery
262
Name 4 differential diagnosis of sinusitis
Allergic rhinitis
Non-allergic rhinitis
Migraine
Adenoiditis
263
Define respiratory failure
Occurs when there is a failure of gas exchange and/or ventilation, leading to abnormalities in PaO2 and PaCO2 on arterial blood gas
264
Define type 1 respiratory failure
Hypoxaemia PaO2 < 8kPa/60mmHg
Normocapnia PaCO2 < 6.0kPa/45mmHg
265
Define type 2 respiratory failure
Hypoxaemia PaO2 < 8kPa/60mmHg
Hypercapnia PaCO2 > 6.0kPa/45mmHg
266
How many values does type 1 respiratory failure affect
1 value (type 1)
PaO2 low
267
How values does type 2 respiratory failure affect
2 values (type 2)
PaO2 - low
PaCO2 - high
268
What does type 1 respiratory failure occur due to
V/Q mismatch
Results in PaO2 falling and PaCO2 rising
Rise in PaCO2 triggers an increase in patients overall alveolar ventilation = corrects PaCO2 but not PaO2
269
Describe why type 2 respiratory failure occurs
Alveolar hypertension - prevents patients from being able to adequately oxygenate and eliminate CO2 from the blood
Leads to PaO2 falling (due to lack of oxygenation) and PaCO2 rising (due to ventilation and elimination of CO2)
270
Name the causes of type 1 respiratory failure
Reduced ventilation and normal perfusion
- pneumonia
- pulmonary oedema
- bronchoconstriction
Reduced perfusion with normal ventilation
- pulmonary embolism
271
Describe the causes of type 2 respiratory failure
Hypoventilation due to
- Increased resistance as a result of airway obstruction e.g. COPD
- Reduced compliance of the lung tissue/chest wall e.g. pneumonia, rib fractures, obesity
Reduced strength of respiratory muscles e.g. Guillain-Barre, motor neurone disease
Reduced respiratory drive - opioids and other sedatives
272
Describe the pathophysiology of whooping cough
Bacteria adhere to ciliated epithelial cells
Causes ciliary paralysis, local tissue damage and inflammation
Can enter and survive with phagocytic leukocytes and non-phagocytic cells
273
Describe the epidemiology of whooping cough
Peak incidence - up to 6 months of age
Mortality high up to 3 months
3% adults with acute cough
274
Describe the cause of whooping cough
Gram negative bacterium - Bordetella pertussis
Transmitted - airborne droplets
Incubation 4-21 days
275
Define whooping cough
Acute respiratory disease
276
What is another name for whooping cough
Pertussis
277
Name 2 risk factors of whooping cough
Unvaccinated or under-vaccinated status
Close contact with an infected person - especially in the household
278
Name the clinical features progression of whooping cough
3 stages - carrhal, paroxysmal, convalescent
1st - upper respiratory infection
2nd - classic signs of pertussis
279
What are the classical signs of pertussis
Cough paroxysms followed by inspiratory whoop and vomiting
Can last up to 10 weeks
Followed by recovery
280
Describe the presentation of a patient where you would suspect whooping cough
2 weeks of cough and coughing paroxysms, post-tussive vomiting, inspiratory whooping, no fever or exposure with someone confirmed
281
Describe the investigations of whooping cough
Culture
PCR
Serology - IgG to the pertussis toxin
282
What is the 1st line investigation of whooping cough
Macrolide antibiotics
First 21 days of illness can prevent transmission
No treatment
283
Does whooping cough have to be announced to local public health agencies
Yes
284
Name the differential diagnosis for whooping cough
Viral upper respiratory infection
Community-acquired pneumonia
TB
Chronic pulmonary disease
GORD
285
Name acute cough related complications
Pneumothorax
Aspiration
Urinary incontinence
Increased risk of rib fractures
Sinusitis
Secondary bacterial pneumonia
Otitis
286
