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Phase 2a > Respiratory > Flashcards

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

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2
Q

What type of inflammation is asthma

A

Type 2

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3
Q

What are the 2 major factors in the pathophysiology of asthma

A

Inflammation

Airway hyper-responsiveness

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4
Q

What parts of the airway are affected by asthma

A

Large airways

Small airway with diameters < 2 micrometres

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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

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6
Q

What cell is involved in near fatal exacerbations of asthma

A

Neutrophils

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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

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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

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9
Q

Name the clinical features of asthma

A

Symptoms = episodic

Diurnal variability - worse at night

SOB

Chest tightness

Dry cough

Wheeze

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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

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11
Q

Name 6 triggers of asthma

A

Infection
Night-time or early morning
Exercise
Animals
Cold, damp or dusty air
Strong emotions

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12
Q

Name the investigations for asthma

A

Spirometry
Reversibility testing
Fractional exhaled nitric oxide
Peak flow
Direct bronchial challenge test

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13
Q

What would a positive test for asthma be in a peak flow

A

Variability > 20%

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14
Q

What type of lung disease is asthma

A

Obstructive

FEV1: FVC < 70%

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15
Q

Describe the route of pharmacological management in asthama

A
  1. Offer SABA reliever
  2. Offer low dose ICS (1st line maintanance therapy
  3. If uncontrolled on low dose ICE add leukotriene receptor
  4. Add LABA in combination with ICS
  5. MART therapy
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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

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17
Q

Describe the role of inhaled corticosteroids in asthma

A

Reduce inflammation and reactivity of the airways

Maintain or prevent symptoms

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18
Q

Describe the role of long acting muscarinic antagonists

A

Block Ach receptors

Dilates the bronchioles and reverses bronchoconstriction

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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

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20
Q

Describe the role of theophylline in asthma

A

Relaxes bronchial smooth muscles and reduces inflammation.

Narrow therapeutic window

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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

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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

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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

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24
Q

What would arterial blood gas show in acute exacerbation of asthma

A

Respiratory alkalosis

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25
Q

Name the differential diagnosis of asthma

A

COPD
Chronic rhinosinusitis
Dysfunctional breathing
Vocal cord dysfunction
Bronchiectasis
Congestive heart failure
Cystic fibrosis

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26
Q

Define bronchiectasis

A

Abnormal dilation of bronchi due to the destruction of the elastic and muscular components of the bronchial wall

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27
Q

Describe the pathophysiology of bronchiectasis

A

Involves permanent dilation of the bronchi

Sputum collects and organisms grow in the wide tube

Results - chronic cough, continuous sputum production and recurrent infections

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28
Q

Name the causes of bronchiectasis

A

Idiopathic
Pneumonia
Whooping cough
TB
Alpha-1 antitrypsin deficiency
Connective tissue disorders
Cystic fibrosis
Yellow nail syndrome

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29
Q

Name 5 risk factors of bronchiectasis

A

Cystic fibrosis
Host immunodeficiency
Previous infections
Congenital disorders of the bronchial airway
Primary ciliary dyskinesia

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30
Q

Name 4 symptoms of bronchiectasis

A

SOB
Chronic productive cough
Recurrent chest infections
Weight loss

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31
Q

Name the signs of bronchiectasis

A

Weight loss

Finger clubbing

Signs of cor pulmonale

Scattered crackles
throughout chest that change or clear with coughing

Scattered wheeze and squeaks

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32
Q

Name the investigations of bronchiectasis

A

Sputum culture

Chest x-ray

High-resolution CT

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33
Q

What is the gold standard for diagnosis of bronchiectasis

A

High-resolution CT

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34
Q

What would be seen on a chest x-ray of bronchiectasis

A

Tram-track opacities

Ring shadows

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35
Q

Describe the general management of bronchiectasis

A

Vaccines
Respiratory physiotherapy
Long-term antibiotics
Inhaled colistin
Long-acting bronchodilators
Long-term oxygen therapy
Surgical lung resection
Lung transplant

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36
Q

Describe the treatment of infective exacerbations of bronchiectasis

A

Sputum culture - before antibiotics

Extended course of antibiotics - usually 7-14 days

Ciprofloxacin

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37
Q

Name 4 differential diagnosis of bronchiectasis

A

COPD

Asthma

Pneumonia

Chronic sinusitis

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38
Q

Define COPD

A

Heterogeneous lung disease state characterised by chronic respiratory symptoms and airflow limitation that is not fully reversible

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39
Q

What does COPD encompass

A

Emphysema, bronchiolitis, chronic bronchitis

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40
Q

Define chronic bronchitis

A

Long-term symptoms of cough and sputum production due to inflammation in the bronchi

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41
Q

Define emphysema

A

Involves damage and dilation of alveolar sacs and alveoli decreasing surface area for gas exchange

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42
Q

What is the hallmark of COPD

A

Chronic inflammation that affects the central and peripheral airways, lung parenchyma and alveoli, and pulmonary vasculature

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43
Q

Name the main components of the pathophysiology of COPD

A

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

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44
Q

What is the main cause of COPD and why?

A

Smoking

Inflammatory response of the lung to noxious particles and gases

Cilia dysfunction and oxidative injury

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45
Q

Name 4 causes of COPD

A

Smoking

Air pollution

Indoor burning of biomass fuels

Occupational exposure to dust, chemical agents and fumes

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46
Q

Name 4 risk factors of COPD

A

Cigarette smoking

Advanced age

Genetic factors

Lung growth and development

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47
Q

Describe the typical presentation of COPD

A

SOB
Cough
Sputum production
Wheeze
Recurrent respiratory infections - particularly in winter

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48
Q

Name the investigations of COPD

A

Spirometry

FEV1

MRC Dyspnoea Scale

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49
Q

Describe spirometry results in COPD

A

Obstructive

FEV1: FVC ratio < 70%

Little of no response to reversibility testing with beta-2 agonists

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50
Q

How is COPD diagnosed

A

Clinical presentation + spirometry

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51
Q

How is the severity of COPD graded

A

Using FEV1

Stage 1 mild to stage 4

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52
Q

What is the 1st line medical management of COPD

A

Short acting bea-2 agonists

Short acting muscarinic receptors - ipratropium bromide

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53
Q

What would be seen on an arterial blood gas of a COPD exacerbation

A

Respiratory acidosis

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54
Q

What would be the 1st line management of an acute COPD exacerbation

A

Regular inhalers or nebulisers

Steroids

Antibiotics

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55
Q

How is asthma differentiated from COPD

A

COPD - airway obstruction is minimally reversible with bronchodilators

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56
Q

Name 3 clinical features which are not present in COPD which should make you think of a differential diagnosis

A

Clubbing

Haemoptysis

Chest pain

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57
Q

Name 4 differential diagnosis for COPD

A

Asthma

Lung cancer

Pulmonary fibrosis

Heart failure

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58
Q

Name the complications of COPD

A

Cor pulmonale

Lung cancer

Recurrent pneumonia

Depression

Pneumothorax

Respiratory failure

Anaemia

Polycythaemia

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59
Q

Define cystic fibrosis

A

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

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60
Q

Describe the pathophysiology of cystic fibrosis

A

Abnormal chloride channel transporter by the epithelial cells result in thick, sticky secretions

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61
Q

What are the key consequences off the pathophysiology of cystic fibrosis

A

Lack of digestive enzymes (pancreas)

Low airway clearance = infections

Male infertility (absence of vas deferens)

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62
Q

Name 2 common colonisers of the lungs in cystic fibrosis

A

Staphylococcus aureus

Pseudomonas aeruginosa

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63
Q

Describe the cause of cystic fibrosis

A

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

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64
Q

Name 3 risk factors of cystic fibrosis

A

Family history of CSF

Known carrier status of both parents

Ethnicity - white

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65
Q

Describe the most common 1st presentation of cystic fibrosis

A

Meconium ileus

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66
Q

Name the symptoms of cystic fibrosis

A

Chronic cough with sputum production

Recurrent resp infections

Loose, greasy stools - steatorrhea

Abdominal pain and bloating

Failure to thrive

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67
Q

Name 5 signs of cystic fibrosis

A

Low weight or height on growth charts

Nasal polyps

Finger clubbing

Crackles and wheezes on auscultations

Abdominal dissention

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68
Q

What is the gold standard diagnostic investigation for cystic fibrosis

A

Sweat test

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69
Q

What are the 3 methods of diagnosis for cystic fibrosis

A

New-born blood spot screening

Sweat test

Genetic testing for CFTR gene

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70
Q

What is the general management of cystic fibrosis divided into

A

For respiratory disease

For GI disease

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71
Q

What is the general treatment of cystic fibrosis in respiratory disease

A

Mucus thinners

Airway clearance

Antibiotics

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72
Q

What is the general management of cystic fibrosis GI disease

A

Aim to help support growth and nutrition

Supplement pancreatic enzymes

Calorie support

Fat soluble vitamins

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73
Q

Name 5 differential diagnosis of cystic fibrosis

A

Asthma

GORD

Chronic aspiration

Failure to thrive

Coeliac disease

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74
Q

Describe the monitoring of cystic fibrosis

A

Follow up every 6 months

Require regular monitoring of sputum for colonisation

Monitoring/screening for diabetes, osteoporosis, vitamin D deficiency and liver failure

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75
Q

Describe the prognosis of cystic fibrosis

A

Life expectancy = 47 years

90% = pancreatic insufficiency

50% = diabetes

30% = liver disease

Most males infertile

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76
Q

Name 6 complications of cystic fibrosis

A

Chronic respiratory failure

Sleep disturbances

Obstructive sleep apnoea

Delayed puberty

Chronic rhinosinusitis

Failure to thrive

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77
Q

Define pleural effusion

A

Collection fluid in the pleural space.

Categorised into:
- exudative = high protein content (> 30 g/L)
- transudative = low protein content (< 30 g/L)

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78
Q

Describe the pathophysiology of pleural effusion

A

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

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79
Q

Name the exudative causes of pleural effusion

A

Related to inflammation - inflammation results in protein leaking out of the tissues into the pleural space

Cancer
Infection
Rheumatoid arthiritis

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80
Q

Name the transudative causes of pleural effusion

A

Relate to fluid moving across or shifting into the pleural space

Congestive cardiac failure
Hypalbuminaemia
Hypothyroidism
Meigs syndrome

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81
Q

Name 4 risk factors of pleural effusion

A

Congestive heart failure
Pneumonia
Malignancy
Recent coronary artery bypass graft surgery

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82
Q

Describe the clinical features of pleural effusion

A

SOB

Examination findings
- dullness to percussion over the effusion
- Reduced breath sounds
- Tracheal deviation away from the effusion (very large effusions)

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83
Q

Name the investigations of a pleural effusion

A

Light’s criteria
X-ray
Imaging
Pleural fluid analysis

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84
Q

Describe lights criteria

A

Used to establish exudative effusion using protein or lactate dehydrogenase

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85
Q

What would be seen on an x-ray of pleural effusion

A

Blunting of the costophrenic angle

Fluid in the lung fissures

Larger effusions will have a meniscus

Tracheal and mediastinal deviation away from the effusion

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86
Q

Describe pleural fluid analysis as an investigation of pleural effusion

A

Sample taken by aspiration of chest drain

Helps establish underlying cause

Measures - Protein content, LDH, cell count, glucose and microbiology testing

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87
Q

Describe the management of pleural effusion

A

Diagnosing + treatment of underlying cause = mainstay

Conservative management
Pleural aspiration
Chest drain

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88
Q

Name 5 differential diagnosis of pleural effusion

A

Pleural thickening

Pulmonary collapse and consolidation

Elevated hemidiaphragm

Pleural tumours

Covid-19

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89
Q

Name a complication of pleural effusion

A

Empyema = infected pleural effusion

Patient with improving pneumonia but new or ongoing fever

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90
Q

What does pleural aspiration show in empyema

How is it treated

A

Pus, low pH, low glucose and high LDH

Chest drain and antibiotics

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91
Q

When would a pleural effusion be likely to reoccur

A

If due to heart failure, cirrhosis or malignancy

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92
Q

Define pneumonia

A

Infection of the lung tissue, causing inflammation in the alveolar space

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93
Q

What is the general rule of bacterial and viral infections in the lungs

A

Lower down the respiratory tract, the higher the probability of bacterial infection, opposed to viral

Upper = generally viral

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94
Q

How can pneumonia be classified

A

Community-acquired pneumonia = develops in the community

Hospital-acquired pneumonia = develops after > 48 hours in
hospital

Ventilator-acquired pneumonia = develops intubated patients in ICU

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95
Q

Define aspiration pneumonia

A

Infection develops due to aspiration of food or fluids, usually in patients with impaired swallowing.

Associated with anaerobic bacteria

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96
Q

Describe atypical pneumonia

A

Caused by an organism that cannot be cultured in a normal way or detected using gram stain.

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97
Q

Name 5 causes of atypical pneumonia

A

Legions of psittaci MCQs

Lesions - legionella pneumophilia

Psittaci - chlamydia penumophillia

M - Mycoplasma pneumoniae

C - Chlamydophila pneumoniae

Qs - Q fever - Coxiella Brunetti

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98
Q

Describe legionella pneumophilia as a cause of atypical pneumonia

A

Inhaling infected water

Caused of SIAH

initial screening = urine antigen

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99
Q

Describe mycoplasma pneumonia as a cause of atypical pneumonia

A

Milder pneumonia

Rash = erythema multiforme

Can cause neurological symptoms

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100
Q

Describe Q fever as a cause of atypical pneumonia

A

Linked to exposure to bodily fluids or animals

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101
Q

Describe chlamydia psittaci as a cause of atypical pneumonia

A

Typically contracted from contact with infected bodies

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102
Q

What are the two typical bacterial causes of pneumonia

A

Streptococcus pneumoniae
Haemophilus

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103
Q

What is the most common cause of pneumonia in patients with HIV

A

Pneumocystis jirovecii

Fungal pneumonia

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104
Q

How is pneumocystis pneumonia treated

A

Co-trimoxazole

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105
Q

Name the risk factors of community acquired pneumonia

A

Age > 65 years

Residence in healthcare setting

COPD

Smoking

Alcohol abuse

Poor oral hygiene

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106
Q

Name the risk factors for hospital acquired pneumonia

A

Poor infection control/hygiene

Intubation and mechanical ventilation

Multidrug resistant bacteria

Aspiration

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107
Q

Name the presenting symptoms of pneumonia

A

Cough
Sputum production
SOB
Fever
Haemoptysis
Pleuritic chest pain
Delirium

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108
Q

Name 3 characteristic chest signs of pneumonia

A

Bronchial breath sounds

Focal coarse crackles

Dullness to percussion

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109
Q

Name the investigations of pneumonia

A

Community (not necessarily need investigations)

Chest x-ray
FBC
Renal profile
C-reactive protein
Sputum cultures
Blood cultures
Pneumococcal and Legionella urinary antigen tests

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110
Q

What is roughly proportional to the severity of infection in pneumonia

A

White blood cells + CRP

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111
Q

What assessment is used to measure the severity of pneumonia

A

CRB-65 or CURB-65 (in hospital)

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112
Q

Describe CURB-65

A

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

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113
Q

Describe the management of mild community acquired pneumonia

A

5 day oral antibiotics
- amoxicillin
- doxycycline
- clarithromycin

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114
Q

Describe the management of moderate or severe pneumonia

A

IV antibiotics

Stepped down to oral

Respiratory support

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115
Q

Name 5 differential diagnosis of pneumonia

A

COVID-19
Cardiogenic pulmonary oedema
ARD
Pleural effusion
Pulmonary embolus

116
Q

Name 6 complications of pneumonia

A

Sepsis

ARDS

Pleural effusion

Empyema

Lung abscess

Death

117
Q

Define TB

A

Infectious disease caused by mycobacterium tuberculosis

118
Q

Describe the pathogenesis of TB

A

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
Q

Describe the disease course of TB

A

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
Q

Describe latent TB

A

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
Q

Describe the cause of TB

A

By mycobacterium TB - bacillus

Hard to culture in the lab

Must be stained using Zeihl-Neelsen stain

122
Q

What bacteria is ‘acid fast bacilli’ that stain red with ‘Zeihl-Neelsen staining’

A

Mycobacterium tuberculosis

123
Q

What are multidrug resistant TB

A

Strains that are resistant to more than 1 TB drug

Makes them difficult to treat

124
Q

Name the risk factors of TB

A

Exposure to infection

Birth in an endemic country

HIV infection

Immunosuppressive medicines

Silicosis

Apical fibrosis

Malnutrition, homelessness, drug users, smokers and alcoholics

125
Q

Describe the clinical features of TB

A

Chronic, gradually worsening symptoms

Cough
Haemoptysis
Lethargy
Fever/night sweats
Weight loss
Lymphadenopathy
Erythema nodosum
Spinal pain

126
Q

What is erythema nodosum

A

Tender, red nodules on shins caused by inflammation of the subcutaneous fat

127
Q

Name the investigation of TB

A

Mantoux test

Interferon-gamma release assay

To show an immune response to TB caused by previous infection, latent TB or active TB

128
Q

What is used to support a diagnosis of TB

A

Chest x-ray

Cultures

NAAT

129
Q

What does pulmonary TB look like on a chest x-ray

A

Patchy consolidation

Pleural effusions

Hilar lymphadenopathy

130
Q

What does reactive TB show on a chest x-ray

A

Patchy or nodular consolidation with cavitation (gas filled spaces) - typically in upper zones

131
Q

What does disseminated millary TB look like on a chest x-ray

A

Millet seeds uniformly distributed across the lung fields

132
Q

Describe the management of latent TB

A

Either:
- Isoniazid + rifampicin for 3 months
- Isoniazid for 6 months

133
Q

Describe the management of active TB

A

RIPE

Rifampicin - 6 months

Isoniazid - 6 months

Pyrazinamide - 2 months

Ethambutol - 2 months

134
Q

What is isoniazid co-prescribed with

A

Pyridoxine (vitamin B6) - prevent peripheral neuropathy

135
Q

Describe the further management for TB

A

Testing for other infectious disease

Testing contacts

Notifying UK health security agency of suspected cases

Isolating patients with active TB

136
Q

Name the differential diagnosis of TB

A

Covid-19

Community-acquired pneumonia

Lung cancer

Non-TB mycobacteria

Fungal infection

137
Q

Describe the side effects of rifampicin

A

Red/orange discolouration of secretions

Potent inducer of C450 enzymes - can reduce effects of drugs metabolised by them e.g. combined contraceptive pill

138
Q

Describe the side effects of isoniazid

A

Can cause peripheral neuropathy

139
Q

Describe the side effects of pyrazinamide

A

Can cause hyperuricaemia

Results in gout and kidney stones

140
Q

Describe the side effects of ethambutol

A

Can cause colour blindness and reduced visual acuity

141
Q

Describe the prognosis of TB

A

Mortality 50% without treatment

Treated - do well

Risk factors for death

142
Q

Define pneumothorax

A

Occurs when air enters the pleural space, separating the lung from the chest wall

143
Q

Describe the pathophysiology of pneumothorax

A

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
Q

Define a tension pneumothorax

A

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
Q

Describe the pathophysiology of a tension pneumothorax

A

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
Q

Describe how tension pneumothorax can be dangerous

A

Pressure inside the thorax to push the mediastinum across

Kink the big vessels in the mediastinum and cause cardiorespiratory arrest

147
Q

Name the causes of pneumothorax

A

Spontaneous

Trauma

Iatrogenic - lung biopsy, mechanical ventilation or central line insertion

Lung pathologies - infection, asthma or COPD

148
Q

Who would get a primary spontaneous pneumothorax

A

Young people without known respiratory illness

149
Q

Who would get secondary spontaneous pneumothorax

A

Patients with pre-existing pulmonary diseases

150
Q

What is the immediate treatment of a tension pneumothorax

A

Decompression

151
Q

Name the risk factors of pneumothorax

A

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
Q

Describe the typical patient of a pneumothorax

A

Tall, thin young man presenting with sudden breathlessness and pleuritic chest pain, possibly whilst playing sport

153
Q

Describe the clinical features of a pneumothorax

A

SOB
Pleuritic chest pain
Dyspnoea

154
Q

Describe the clinical symptoms of a tension pneumothorax

A

Distressed
Rapid laboured respirations
Cyanosis
Profuse diaphoresis
Tachycardia

155
Q

Name 5 signs of a tension pneumothorax

A

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
Q

What is the 1st line investigation of a pneumothorax

A

Erect chest x-ray

157
Q

What would be seen on a erect chest x-ray in a pneumothorax

A

Areas between the lung and chest walls with no lung markings

Line demarcating the edge of the lung

Measuring the size

158
Q

What is the alterative investigation for a pneumothorax

A

CT thorax

Detect when too small to be seen on a chest x-ray

Can be used to assess size correctly

159
Q

Describe how management is decided for a pneumothorax

A

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
Q

What is the main treatment of a pneumothorax

A

Chest drain

161
Q

Describe a chest drain in a pneumothorax

A

For - unstable, bilateral or secondary

In triangle of safety - avoid the neurovascular bundle.

repeat x-ray

162
Q

Describe the triangle of safety

A

5th intercostal space

Midaxillary line

Anterior axillary line

163
Q

Why would surgery be done in a pneumothorax

A

Chest drain fails to correct

Persistent air leak in drain

Reoccurs

164
Q

What is the surgery that can be completed on a pneumothorax

A

Video-assisted thoracoscopic surgery (VATS)

165
Q

Describe the management of a pneumothorax

A

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
Q

Name differential diagnosis of pneumothorax

A

Asthma/COPD acute exacerbation

Pulmonary embolism

Myocardial ischemia

Pleural effusion

Fibrosing lung disease

167
Q

Name complications of chest drain

A

Air leaks around the drain site

Surgical emphysema

168
Q

Describe empyema

A

Presence of pus in the pleural space

169
Q

Describe the pathophysiology of empyema

A
  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
Q

Name the main cause of empyema

A

Follows bacterial pneumonia

171
Q

Name 5 risk factors of empyema

A

Pneumonia
Iatrogenic interventions in the pleural space
Thoracic trauma
Immunocompromised state
Comorbid lung disease

172
Q

Describe the presentation of empyema

A

Patients with improving pneumonia but a new or ongoing fever

173
Q

Name 4 features which can be seen on a physical examination of empyema

A

Dullness to percussion on the affected area

Egophonia

Increased palpable fremitus

Fine crackles

174
Q

Name a scoring system of empyema

A

RAPID

175
Q

Describe the RAPID scoring system of empyema

A

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
Q

Name the investigations of empyema

A

Chest x-ray
Ultrasound
CT scan
Pleural aspiration

177
Q

Name 4 findings on an aspiration of empyema

A

Pus

Low pH

Low glucose

High LDH

178
Q

Name the management of empyema

A

Chest drain

Antibiotics

Surgery

179
Q

Name the differential diagnosis of empyema

A

Pneumonia
Lung abscess
Malignant pleural effusion
Oesophageal rupture
Haemothorax

179
Q

Describe the antibiotics of empyema

A

Empirical IV antibiotics

Penicillin’s

OR

Penicillin’s combined with beta-lactamase, cephalosporins and metronidazole

180
Q

Name 3 complications of empyema

A

Septic shock
Respiratory failure
Chest drain complications

181
Q

Describe the prognosis of empyema

A

Approx. 24% need surgery

Mortality 15-20%

182
Q

Define croup

A

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
Q

Describe the pathophysiology of croup

A

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
Q

What is the common cause of croup

A

Viral infection - parainfluenza virus type 1 or 3

185
Q

Name the risk factors of croup

A

Age 6 months to 6 years

Weak - male sex, prior intubation

186
Q

Name the clinical features of croup

A

Upper airway obstruction

Seal-like barky cough
Stridor
Voice hoarseness
Respiratory distress

187
Q

Name the investigation of croup

A

Clinical investigation

188
Q

What is the 1st line management of all causes of croup

A

Oral corticosteroids - dexamethasone

189
Q

In moderate to severe croup what would be given in addition to the 1st line treatment

A

1st line = dexamethasone

+ nebulised epinephrine (adrenaline)

190
Q

Name the differential diagnosis of croup

A

Bacterial tracheitis
Epiglottis
Foreign body in the upper airway
Retropharyngeal abscess
Allergic reaction

191
Q

Name the complications of croup

A

If upper airway obstruction worsens - respiratory failure can result

Asynchronous chest
Abdominal wall motion
Fatigue
Hypoxia
Hypercapnia

192
Q

Define hypersensitivity pneumonitis

A

Inflammation of the alveoli and distal bronchioles caused by an immune response to inhaled allergens

193
Q

Describe the pathophysiology of hypersensitivity pneumonitis

A

Result from non-IgE mediated immunological inflammation

Caused by repeated inhalation of non-repeated protein

Inflammation in the alveoli and distal bronchioles

194
Q

Name 2 main causes of hypersensitivity pneumonitis

A

Bacteria - actinomycetes

Animal proteins - avian protein

195
Q

Name 4 causes of hypersensitivity pneumonitis

A

Bacteria
Animal proteins
Fungi
Reactive chemicals

196
Q

Name risk factors of hypersensitivity pneumonitis

A

Smoking
Viral infection
Exposure to..

197
Q

Name clinical features of hypersensitivity pneumonitis

A

Fever
Tachypnoea
Dyspnoea
Restrictive function tests
Reduced diffusing capacity to carbon monoxide

198
Q

What would be seen in the later stages of hypersensitivity pneumonitis

A

Malaise
Weight loss
Dyspnoea
Cough

199
Q

Name the investigations of hypersensitivity pneumonitis

A

Chest x-ray
Chest CT
Serum antigen specific IgG or IgA
Pulmonary function test

200
Q

What would be seen on a chest x-ray of hypersensitivity pneumonitis

A

Infiltrates
Nodular or patchy fibrosis

201
Q

Describe the management of hypersensitivity pneumonitis

A

1st line - avoidance of antigen

Smoking cessation, pulmonary rehabilitation, supplemental oxygen

Corticosteroids

202
Q

Name the differential diagnosis of hypersensitivity pneumonitis

A

Viral pneumonia
Sarcoidosis
Idiopathic pulmonary fibrosis

203
Q

Name 3 complications of hypersensitivity pneumonitis

A

Progressive deterioration in the lung function

Hypoxaemia

Death

204
Q

Describe the histology of lung cancer

A

Small-cell (20%)

Non-small cell (80%)
- adenocarcinoma
- squamous cell carcinoma
- large-cell carcinoma
- other types

205
Q

Describe the epidemiology of lung cancer

A

3rd most common cancer

80% thought to be preventable

206
Q

Name the main risk factor/cause of cancer

A

Smoking

Other - radon gas

207
Q

Describe the general clinical features of lung cancer

A

SOB
Cough
Haemoptysis
Finger clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy

208
Q

What is generally the 1st sign of lung cancer found on examination

A

Lymphadenopathy - supraclavicular nodes

209
Q

Name the extrapulmonary manifestations of lung cancer

A

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
Q

Describe Horner’s syndrome

A

Triad
- ptosis
- anhidrosis
- miosis

Can be caused by a Pancoast tumour (tumour pulmonary apex) - pressing on sympathetic ganglion

211
Q

Describe limbic encephalitis

A

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
Q

Describe lambert-eaton myasthenic syndrome

A

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
Q

Name the 1st line investigation of lung cancer

A

Chest x-ray

214
Q

What findings on a chest x-ray would be suggestive of lung cancer

A

Hilar enlargement
Peripheral opacity
Pleural effusion
Collapse

215
Q

Name investigations of lung cancer

A

Chest x-ray
Staging CT scan - contrast
PET-CT
EBUS
Histological diagnosis

216
Q

Describe bronchoscopy with endobronchial ultrasound (EBUS) as an investigation of lung cancer

A

Allows detailed assessment of the tumour and ultrasound guided biopsy

217
Q

Describe the referral criteria for lung cancer

A

Offer chest x-ray (2 weeks) to patients over 40 with 5 symptoms or smoking status with symptoms

218
Q

What are the surgical options of lung cancer

A

Segmentectomy or wedge resection

Lobectomy

Pneumonectomy

219
Q

Name 5 differential diagnosis of lung cancer

A

Pneumonia/bronchitis
Carcinoid tumour
Infectious granuloma
Sarcoidosis
Rheumatoid arthritis

220
Q

Define small-cell lung cancer

A

Malignant epithelial tumour arising from cells lining the lower respiratory tract

221
Q

Describe the pathophysiology of small-cell lung cancer

A

Cells contain neurosecretory granules that release neuroendocrine hormones.

Tend to arise in the central lung with mediastinal involvement

Aggressive malignancy

222
Q

Name 3 risk factors of small-cell lung cancer

A

Cigarette smoking
Environmental tobacco exposure
Radon gas exposure

223
Q

What extra pulmonary symptoms can be seen in small-cell lung cancer

A

Syndrome of inappropriate ADH (SIADH)

Cushing’s syndrome

Limbic encephalitis

Lambert-Eaton myasthenic syndrome

224
Q

Describe the treatment of small-cell lung cancer

A

Localised = chemotherapy + radiotherapy

Extensive = chemotherapy + immunotherapy

Surgery
Palliative radiotherapy

225
Q

What is the prognosis of small-cell lung cancer

A

Generally worse than non-small cell lung cancer

226
Q

Define mesothelioma

A

Aggressive epithelial neoplasm arising from the lining of the lung, abdomen, pericardium or tunica vaginalis

227
Q

Describe the pathophysiology of mesothelioma

A

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
Q

Describe the epidemiology of mesothelioma

A

20-40 year latent period between exposure and development

6-9th decade of life

Rare

229
Q

Name the causes of mesothelioma

A

One of few cancers related directly between exposure and development

Asbestos

230
Q

Name the clinical features of mesothelioma

A

Shortness of breath
Chest pain

Unilateral pleural effusion and pleural thickening

231
Q

Describe the treatment of mesothelioma

A

Operable
- trimodal therapy
- with chemotherapy, surgery, and hemi thoracic radiotherapy

Inoperable
- chemotherapy or immune checkpoint inhibitor therapy

232
Q

What is the prognosis of mesothelioma

A

Poor

233
Q

Define non-small cell cancer

A

Compromises of a group of malignant epithelial tumours arising from the cells lining the lower respiratory tract

234
Q

Name 5 risk factors of non-small cell lung cancer

A

Cigarette smoking

Environmental tobacco exposure

COPD

Family history

Radon gas exposure

235
Q

Name 5 clinical features of non-small lung cancer

A

Cough
Chest pain
Haemoptysis
Dyspnea
Weight loss

236
Q

What is the 1st line treatment for non-small cell lung cancer

A

Surgery

When isolated to a single area

237
Q

Describe the treatment of non-small cell lung cancer

A

1st line = surgery

Radiotherapy
Chemotherapy - later stages (palliative)

238
Q

Describe adenocarcinoma

A

Most common overall - including nonsmokers, young adults and women

Begins in glands of alveoli, usually in outer part of lung

Typically slow growing

239
Q

Describe large cell lung carcinoma

A

Least common

Begins in large cells found anywhere in the lungs, but mostly in the outer part

Typically fast growing

240
Q

Describe squamous cell carcinoma

A

2nd most common overall - most common in smokers

Begins in squamous cells in the bronchi - usually in centre of lungs

Typically slow growing

241
Q

Define otitis media

A

An infection in the middle ear

242
Q

Describe the pathophysiology of otitis media

A

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
Q

What is the most common cause of otitis media

A

Streptococcus pneumonia (also causes rhinosinusitis and tonsilitis)

244
Q

Name 4 causes of otitis media

A

1st = streptococcus pneumonia

Haemophilus influenza
Moraxella catarrhalis
Staphylococcus aureus

245
Q

Name the risk factors of otitis media

A

Childcare attendance
Older siblings
Young age
Family history

246
Q

Name the clinical features of otitis media

A

Ear pain and reduced hearing (affected ear)

General symptoms of upper airway infection

May affect vestibular system or tympanic membrane

247
Q

If otitis media affects the vestibular system what would the clinical features be

A

Balance issues
Vertigo

248
Q

If otitis media affects the tympanic membrane what would the clinical features be

A

Discharge from the ear

249
Q

Name the investigation of otitis media

A

Otoscope

250
Q

Describe otoscope investigation of otitis media

A

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
Q

Describe the management of otitis media

A

Antibiotics - 1st line - amoxicillin 5 days

Simple analgesia

252
Q

Name 4 differential diagnosis of otitis media

A

Otitis media with effusion

Myringitis

Mastoiditis

Cholesteatoma

253
Q

Name the possible complications of otitis media

A

Hearing loss - temporary
Perforated eardrum
Recurrent infection

Rare
- mastoiditis
- abscess

254
Q

Define sinusitis

A

Inflammation of the paranasal sinuses in the face.

Usually accompanied by inflammation of the nasal cavity (rhinosinusitis)

255
Q

Describe the pathophysiology of sinusitis

A

Blockage of ostia prevents drainage of the sinuses

256
Q

Name the causes of sinusitis

A

< 10 days - viral
> 10 days - bacterial

Infection
Allergies
Obstruction of drainage
Smoking

257
Q

Name 3 risk factors of sinusitis

A

Asthma - increases risk

Viral upper respiratory tract infection

Allergic rhinitis

258
Q

Describe the clinical features of sinusitis

A

Recent viral upper respiratory tract infection

Nasal congestion, discharge
Facial pain, headache, pressure, swelling

Loss of smell

259
Q

Describe the investigations of sinusitis

A

Most cases = no investigations

If continue
- nasal endoscopy
- CT scan

260
Q

Describe the management of acute sinusitis

A

Antibiotics (after 10 days)

High dose steroid nasal spray 14 days

261
Q

Describe the management for chronic sinusitis

A

Saline nasal irrigation

Steroid nasal sprays or drops

Functional endoscopic sinus surgery

262
Q

Name 4 differential diagnosis of sinusitis

A

Allergic rhinitis
Non-allergic rhinitis
Migraine
Adenoiditis

263
Q

Define respiratory failure

A

Occurs when there is a failure of gas exchange and/or ventilation, leading to abnormalities in PaO2 and PaCO2 on arterial blood gas

264
Q

Define type 1 respiratory failure

A

Hypoxaemia PaO2 < 8kPa/60mmHg

Normocapnia PaCO2 < 6.0kPa/45mmHg

265
Q

Define type 2 respiratory failure

A

Hypoxaemia PaO2 < 8kPa/60mmHg

Hypercapnia PaCO2 > 6.0kPa/45mmHg

266
Q

How many values does type 1 respiratory failure affect

A

1 value (type 1)

PaO2 low

267
Q

How values does type 2 respiratory failure affect

A

2 values (type 2)

PaO2 - low

PaCO2 - high

268
Q

What does type 1 respiratory failure occur due to

A

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
Q

Describe why type 2 respiratory failure occurs

A

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
Q

Name the causes of type 1 respiratory failure

A

Reduced ventilation and normal perfusion
- pneumonia
- pulmonary oedema
- bronchoconstriction

Reduced perfusion with normal ventilation
- pulmonary embolism

271
Q

Describe the causes of type 2 respiratory failure

A

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
Q

Describe the pathophysiology of whooping cough

A

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
Q

Describe the epidemiology of whooping cough

A

Peak incidence - up to 6 months of age

Mortality high up to 3 months

3% adults with acute cough

274
Q

Describe the cause of whooping cough

A

Gram negative bacterium - Bordetella pertussis

Transmitted - airborne droplets

Incubation 4-21 days

275
Q

Define whooping cough

A

Acute respiratory disease

276
Q

What is another name for whooping cough

A

Pertussis

277
Q

Name 2 risk factors of whooping cough

A

Unvaccinated or under-vaccinated status

Close contact with an infected person - especially in the household

278
Q

Name the clinical features progression of whooping cough

A

3 stages - carrhal, paroxysmal, convalescent

1st - upper respiratory infection

2nd - classic signs of pertussis

279
Q

What are the classical signs of pertussis

A

Cough paroxysms followed by inspiratory whoop and vomiting

Can last up to 10 weeks

Followed by recovery

280
Q

Describe the presentation of a patient where you would suspect whooping cough

A

2 weeks of cough and coughing paroxysms, post-tussive vomiting, inspiratory whooping, no fever or exposure with someone confirmed

281
Q

Describe the investigations of whooping cough

A

Culture

PCR

Serology - IgG to the pertussis toxin

282
Q

What is the 1st line investigation of whooping cough

A

Macrolide antibiotics

First 21 days of illness can prevent transmission

No treatment

283
Q

Does whooping cough have to be announced to local public health agencies

A

Yes

284
Q

Name the differential diagnosis for whooping cough

A

Viral upper respiratory infection

Community-acquired pneumonia

TB

Chronic pulmonary disease

GORD

285
Q

Name acute cough related complications

A

Pneumothorax
Aspiration
Urinary incontinence
Increased risk of rib fractures
Sinusitis
Secondary bacterial pneumonia
Otitis

286
Q
A

Phase 2a (15 decks)

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