Respiratory Flashcards
What is COPD?
Progressively worsening, irreversible airflow obstruction
Types of respiratory failure and pathophysiology?
Type 1 = fibrosis related causes, lung fails to fill properly which results in ↓PaO2, ↓PaCO2 Type 2 = obstructive causes. Lung fails to remove CO2 properly which results in ↓PaO2 + ↑PaCO2.
Conditions that cause type 2 respiratory failure?
Asthma and COPD
Treatment for type one respiratory failure?
CPAP - continuous positive airway pressure
Treatment for type 2 respiratory failure?
BIPAP - bi positive airway pressure
Types of COPD?
Chronic Bronchitis Emphysema A1AT deficiency
Risk factors for COPD?
Cigarettes Air pollution Genetics (A1AT deficiency = auto recessive) Older males
Pathophysiology of chronic bronchitis?
- Hypertrophy + hyperplasia of mucous glands (mucous is protective against damage) - Chronic inflammation cells infiltrate bronchi and bronchioles - This causes: - mucus hypersecretion - ciliary dysfunction - narrowed lumen (thus increased infection risk + airway trapping)
Typical presentation of chronic bronchitis?
Chronic purulent cough, dysponea for 3+months, over 2 years with sputum “blue bloater” (blue tint of skin and lips due to cyanosis and typically overweight- not a respectful term to use nowadays)
Pathophysiology of Emphysema?
Destruction of elastin layer in alveolar ducts/alveolar sacs/respiratory bronchioles - elastin keeps walls open during expiration (bernouli principle) - decreased elastin = air trapping distal to blockage
Types of Emphysema?
Centriacinar Emphysema Panacinar Emphysema Distal Acinar Irregular Emphysema
Most common type of Emphysema?
Centracinar emphysema very common in smokers
Most severe type of emphysema?
Panacinar emphysema caused by A1AT deficiency
What area of the lungs does centriacinar emphysema effect?
Respiratory bronchioles only
What area of the lungs does Panacinar emphysema effect?
respiratory bronchioles - alveolar ducts - alveolar sacs - alveoli
Pathophysiology of A1AT deficiency?
A1 antitrypsin degrades NE (neutrophil elastase) which protects excess damage to elastin layer especially in lungs - Deficiency (decreased liver production) = ↑NE = panacinar emphysema and liver issues
What is A1AT deficiency caused by?
Autosomal codominant inheritance
Typical patient presentation to suspect A1At deficiency in?
Younger/middle aged men with COPD symptoms but no smoking history
Symptoms of COPD?
Typically: - older patient - chronic cough - with (often) purulent (infectious) sputum - extensive smoking history (exception A1AT) - constant dyspnoea (not episodic)
Presentation of a pink puffer?
Minimal cough - Pursed lip breathing - Cachectic (muscle wastage) - Barrel Chest - Hyperesonant percussion
Complication of pink puffer patients?
Bullae rupture - if subpleural = pneumothorax
Do patients present with only blue bloater or pink puffer?
These aren’t separate conditions and most patients present with a mix of both
Dyspnoea grading scale MRC 1-5?
1- strenuous exercise 5- can’t do daily activities without SOB eg. change clothes
Main investigation to diagnose COPD?
Pulmonary function test: - Increasing fractional expired number indicates lung damage - FEV1:FVC <0.7 = obstruction on PFT spirometry
What are the 2 conclusions from the diagnostic test and the values associated with them?
Bronchodilator irreversible <12% ↑FEV1 = COPD Bronchodilator reversible >12% ↑FEV1 = Asthma
Other investigations to diagnose COPD?
- DLCO (diffusing capacity of CO across lung) = low in COPD, normal in asthma - Genetic test for A1AT deficiency - ABG/ECF/CXR (may show flattened diaphragm + bullae formation)
Complications of COPD?
Cor pulmonale (RHS heart failure due to increased portal hypertension + infection risk)
Main pathogens in acute COPD exacerbations?
S.Pneumo - H.Influenzae(as these patients are increasingly susceptible to infection)
Treatment for COPD?
- First smoking cessation + vaccines (influenza + pneumococcal) Long term management (more key): 1) SAB2A (salbuterol) 2) SAB2A + LAB2A (salmeterol) + LAM3A (tiotropium) 3) SAB2A + LAB2A + LAM3A + ICS *consider long term oxygen if v.severe - 15h+ for 3 weeks
When is oxygen given to severe COPD patients?
O2 <88% (55mmHg) or O2 <90% (60mmHg) with heart failure *for long term oxygen therapy must be non smoker and readings of <7.3KPa consistently
How to treat episodes of acute COPD exacerbation in hospital?
- O2 target is 88-92% saturation - as these patients are chronic CO2 retainers, excess O2 = increased dead space= increased V/Q mismatch and CO2 retention => respiratory acidosis Treatment: - nebulised salbutamol + ipratropium bromide - ICS - Antibiotics
What is asthma?
Chronic reversible airway disease characterised by: - reversible airway obstruction - airway hyperresponsiveness - inflamed bronchioles - mucus hypersecretion
What increases the risk of susceptibility to asthma infection?
Hygiene Hypothesis = Growing up in a very hygienic environment
What are the types of asthma and prevalence?
1) Allergic (70%) 2) Non allergic (30%)
What does allergic asthma entail?
- IgE mediated - Extrinsic - T1 hypersensitivity - Due to environmental trigger (pollen, smoke etc.) - Often early presentation –> childhood diagnosis - Consider genetics + hygiene hypothesis
What does non-allergic asthma entail?
Non IgE mediated - Intrinsic - may present later - Harder to treat - Associated with smoking (like COPD)
What are the triggers for asthma?
infection - Allergen - Cold weather - Exercise - Drugs (Beta blockers, aspirin)
What is the atopic triad?
1) Atopic rhinitis 2) Asthma 3) Eczema (some people have 3 conditions synonymously - known as ATOPY)
What is Somter’s triad?
1) nasal polyps 2) asthma 3) aspirin sensitivity
What is the pathophisiology of Asthma?
- overtime = chronic remodelling (bronchial scarring —> decreased lumen size —> increased mucus)
What happens with asthma overtime?
=> chronic remodelling bronchial scarring —> decreased lumen size —> increased mucus
Symptoms of asthma?
Wheeze - Cough (typically dry) - Chest tightness - SOB (shortness of breath) - typically episodic w/triggers and diurnal variation - Often younger patient
What may be found in microscopy of mucus in asthma?
May show Curschmann’s spirals + Lexton Charcot crystals
How can asthma episodes be classified?
- Moderate (PEF 50-75%) - Severe (PEF 33-50%) - can’t finish sentences - Life Threatening (PEF <33%) - decreased consciousness - Fatal (hypercapnic pKa 6+)
Investigations to diagnose asthma?
Spirometry: FeNO ↑ and spirometry shows obstruction (FEV1:FVC <0.7) => Ratio will determine if its bronchodilator reversible/irreversible
What does bronchodilator reversible indicate, give relevant values
Diagnosis = asthma >12% FEV1↑
What does bronchodilator irreversible indicate, give relevant values
Diagnosis = COPD <12% improved FEV1
Give examples for SABA, LABA, SAMA, LAMA?
SABA = salbutamol LABA = salmeterol SAMA = ipratropium bromide LAMA = tiotropium bromide
Define SABA, LABA, SAMA, LAMA?
SABA = short acting beta agonist LABA = long acting beta agonist SAMA = short acting muscarinic antagonist LAMA = long acting muscarinic antagonist
Treatment guidelines for asthma?
1) SAB2A (PRN) 2) SAB2A + ICS (hydrocortisone) (before adding more meds, review inhaler technique + compliance) 3) SAB2A + ICS + LTRA (leukotriene receptor antagonist eg. Montelukast) 4) SAB2A + ICS + LAB2A +/- LTRA 5) increase ICS dose =very very important!!
Treatment for exacerbations in asthma?
OHSHITME - O2 - SABA (nebuslised) - Hydrocortisone (ICS) - IV MgSO4 (bronchodilation) - Theophylline IV - MgSO4 IV - Escalate (also BIPAP as asthma patients and +/- antibiotics if infection present)
The locations of primary lung cancer?
img
Location of primary metastasis sites?
Bone - liver - Adrenals (usually asymptomatic) - Brain - Lymph nodes
What is mesothelioma?
Malignancy of pleura
Cause of mesothelioma?
Asbestos! - doesn’t present till decades after exposure (latent period)
Who does mesothelioma tend to affect?
Males, 40-70yrs old
Symptoms of Mesothelioma?
Cancer symptoms: 1) weight loss 2) tired all the time 3) night pain Lung symptoms: - shortness of breath - persistent cough - pleuritic chest pain - tumour may press on nearby structures - recurrrent laryngeal (hoarse voice) - signs of metastasis e.g bone pain
Investigations to diagnose mesothelioma?
CXR + CT: 1st line - pleural thickening +/- effusion CA-125 (cancer antigen 125) increased - sensitive not specific - (non specifically raised in many tumours) Biopsy = diagnostic
Treatment for mesothelioma?
Very aggressive tumour => usually palliative BUT doesn’t distantly metastasise as pleura isn’t everywhere - If found early can try surgery + chemo/radiotherapy ( but generally resistant)
What is bronchial carcinoma?
Primary malignancy of lung parenchyma
Types of bronchial carcinoma and prevalence of each?
Small cell (15%) Non small cell (85%)
What is BALT lymphoma?
A non Hodgkin lymphoma originating in bronchi (Bronchial Associated Tissue Lymphoma)
Who does small cell bronchial carcinoma affect?
Exclusively smokers
Causes of small cell bronchial carcinoma?
Paraneoplastic syndromes: - Ectopic ACTH -> cushings - Ecoptic ADH -> SIADH - Lambert Eaton syndrome (autoimmune disorder of NMJ)
Features of small cell bronchial carcinoma?
Fast growing - early metastases - Central lung lesions
Types of non small bronchial cancers and prevalence?
- Squamous (25%) - Adenocarcinoma (40%) - Carcinoid tumour - Large cell
Features of squamous cell bronchial carcinoma?
- Mostly affects smokers - Affects central lung, lesions with central necrosis - May secrete PTHrP -> hypercalcemia - Arise from lung epithelium - Late metastases, locally spread mostly
What condition is heavily associated with non small cell lung carcinoma?
Hypertrophic Pulmonary Osteoarthropathy - a paraneoplastic syndrome - usually squamous cell carcinoma
Key features of Hypertrophic Pulmonary Osteoarthropathy?
Clubbing - Arthritis - Periostitis
What does adenocarcinoma in situ mean?
Stage 0 => not yet spread
What are the features of adenocarcinoma?
Commonly asbestos caused (also in smokers but less so than Squamous) - affects peripheral lung - Arises from mucous secreting glandular epithelium - metastases common in: Bone, Brain, Adrenals, Lymph nodes, liver
What is carcinoid tumour associated with?
Genetics: - MEN1 mutation - Neurofibromatosis 1
What is a carcinoid tumour?
Neuroendocrine tumour (secretes serotonin) - Arises in GIT and sometimes lung - Symptoms only appear when liver metastases are present
What is the biggest cause of secondary hypertrophic osteoarthritis?
Adenocarcinoma Triad: - Clubbing - Arthritis - Long bone swelling
General symptoms of bronchial carcinoma?
- Chest pain - Cough - Haemoptysis (cough up blood from lungs/bronchial tubes) - cancer symptoms - Signs of metastases: - hoarse voice - recurrent laryngeal nerve - Pemberton sign - mediastinal mass - Homer’s syndrome - Pancoast tumour
What is a Pancoast tumour?
Tumour in lung apex metastasises to neck’s sympathetic plexus => causing horner’s syndrome: - ptosis - myosis (XS pupil constriction) - anhidrosis (lack of sweat) *typically on half the face
Investigations to diagnose bronchial carcinoma?
Imaging is 1st line - CXR, CT Diagnostic - bronchoscopy + biopsy Staging is done by MRI (TNM)
Treatment of small cell bronchial carcinoma?
More aggressive; - If early = consider chemo/radio (often unsuccessful) - If metastasised = palliative
Treatment of non small cell carcinoma?
Less aggressive - If early = surgical excision - If metastasised = chemo +/- radio Eg. MAb therapy- Cetuximab vs epidermal growth factor
Are secondary or primary lung tumours more common?
Secondary are much more common
Why are secondary lung tumours more common?
Lungs oxygenate 100% blood => all blood comes to lungs so higher metastasis risk - Especially in the breast, kidney, bowel, bladder
What is a pulmonary embolism?
Pulmonary artery circulation blocked by blood clot - typically embolising from a DVT
Risk factors for PE?
- Anything affecting Virchow’s triad - Fmily history
Pathophysiology of PE?
1) DVT embolises + enters right heart via IVC 2) Occluding pulmonary artery small vessels - decreased V/Q= vent with no perfusion => reactive bronchoconstriction causing increased dyspnoea and smaller airways) 3) Embolus = increased pulmonary BP Pulmonary htn –> RV strain = cor pulmonale + right heart failure
Symptoms of PE?
- Sudden onset SOB - Chest pain (pleuritic) w/swollen painful calf (from DVT) - History of immobility (after surgery/flight) - ↑JVP - Tachypnoea
Signs of RH failure?
1) Hypotensive 2) Tachycardic 3) Peripheral oedema
Investigations to diagnose PE
- ECG - DUSS shows DVT (vein doesn’t compress when squeezed) - CXR is usually normal
ECG characteristics of PE?
S1Q3T3: - S waves deep in lead I - Q waves very deep in lead III - T waves inverted in lead III - RBBB V1-3 = RSR pattern due to right axis deviation - Sinus Tachycardia
Treatment of PE if patient is haemodynamically stable?
Anticoagulants: 1st line = DOAC (apixaban) or LMWH (if DOAC CI) 2nd line = Warfarin
Treatment of PE if patient is haemodynamically unstable?
Thrombolysis (clot busting) i.e alteplase - If that fails catheter embolectomy
Differential diagnosis for PE?
Pleural effusion + pneumothorax which are visible on CXR
Prophylactic treatment for PE?
- Compression stockings - Regular walking, - SC LMWH
Name two types of lower respiratory infections?
Pneumonia - TB
What is Pneumonia?
Fluid exudation into alveoli Due to inflammation from infection - typically bacterial but can be viral
Two types of Pneumonia?
1) CAP - community acquired pneumonia 2) HAP - hospital acquired pneumonia (>48h of hospital admission)
The common bacterial causes of CAP?
S.pneumoniae (most common) - H.Influenzae - Mycoplasma pneumoniae (causes atypical Pneumonia)
The rarer bacterial causes of CAP and treatment?
- S.Aureus - Legionalla (comes from spain) - Chlamydia pneumoniae (atypical pneumonia) => not b lactam susceptible so use macrolide to treat (clarithromycin)
Viral causes of pneumonia?
H. flu - CMV
Fungal causes of Pneumonia?
P.jirovecci -> only in immune compromised patients eg. HIV
Bacterial causes of HAP?
P.puruginosa - E.coli - Klebsiella All gram -ve aerobic bacilli also MRSA
Why is HAP normally more severe than CAP?
Increased severity as many of the causes are multi drug resistant (MDR)
How do people typically get infected with pneumonia?
Typically from inhaled pathogens, can also be from aspiration
Risk factors of pneumonia?
- Immunocompromised (HIV/long term steroids) - IVDU (S.aureus) - Pre existing respiratory disease - Very young/old
Pathophysiology of typical pneumonia?
Bacteria invades and exudate forms inside alveoli lumen - SPUTUM
Pathophysiology of atypical pneumonia?
Bacteria invades and exudate forms inside interstitium of alveoli - dry Cough (eg M.pneumoniae)
Symptoms of typical pneumonia?
Productive Cough with nasty coloured SPUTUM (purulent) - Pyrexia- Due to infection - pleuritic Chest pain, worse w/breathing + Cough - Tachypnoea - Dyspnoea - Tachycardia - Hypotension - Confusion in elderly
Symptoms of atypical pneumonia?
dry Cough - low grade fever
Investigations to diagnose Pneumonia?
1st line diagnostic = CXR shows consolidation - Can show “Air bronchogram” = air-filled bronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white) = diagnostic sign - Sputum sample + culture to ID organism (gram stain, Ziehl Nielsen stain)
Which causes of pneumonia show multilober lesions on CXR?
S.pneumoniae - S.Aureus - Legionella
What are the types of pneumonic lesions on CXR?
Multilobar - Multiple abscesses - Upper lobe
Which cause of pneumonia can cause multiple abscesses on CXR?
S.aureus
Which cause of pneumonia can cause upper lobe pneumonic lesions on CXR?
Klebisella but exclude TB first
Scores for assessing severity of CAP?
CURB 65 - scored out of 5 - 1 = 3% mortality, outpatients - 2 = consider short hospital stay and antibiotics - ≥3 = 15% mortality, hospital ICU stay
How to assess severity of CAP?
CURB 65 - Confusion - Abbreviated Mental Test Score (AMTS) ≤8/10 - Urea nitrogen >7mmol/L - Respiratory rate >30 - BP <90/60mmHg (either <90 sys or <60 dys) - 65+ y/o
Treatment for Pneumonia?
- O2 (stats 94-98%) - Broad spectrum antibiotics - Analgesia (NSAIDS) for pleuritic chest pain unless COPD
Antibiotic guidelines for CURB 0 to 2?
Amoxicillin
Antibiotic guidelines for CURB 3 to 5?
Co-amoxiclav +Clarithromycin
Exceptions with antibiotic treatment for pneumonia?
Legionella needs clarithromycin 1st line and its a notifiable disease (PHE)
What is aspiration pneumonia and which patients is it seen in?
aspiration of gastric contents into lungs => can be fatal due to destructiveness of gastric acid - seen in patients with stroke, Bulbar palsy and Myasthenia gravis
What is TB?
Granulomatous caseating disease, caused by mycobacteria
Causes of TB?
Many mycobacteria species (eg M.Leprae- Leprosy) but 4 species are known as mycobacterium tuberculosis complex (MTC) which cause TB
Mycobacterium Tuberculosis Complex?
1) M.tuberculosis 2) M.africanum 3) M.microtis 4) M.bovis (from unpasteurised milk) =most common causes of TB
Where is TB most common in world?
South Asia (India, China, Pakistan) - Sub-Saharan Africa
Epidemiology of TB?
1.7bn people worldwide (mostly latent)
How is TB spread?
Airborne
Risk factors for TB?
Country + travel association (eg.India) - Immunocompromised - Homeless/crowded housing - IVDU - smoking + alcohol - Increased age
Features of MTC (mycobacterium tuberculosis complex)?
- Non motile + non spore forming - Mycolic acid capsule - Resistant to phagosome killing - Slow growing (15-20 hrs)
Pathophysiology of TB?
1) TB phagocytosed but resist killing, thus forming caseous granulomatous 2) T cells recruited + central region of granuloma undergoes caseating necrosis (primary Ghon focus in upper parts of lung) 3) Ghon focus (lesion) spreads to nearby lymph nodes - ghon complex 4) 2 possibilities: if TB spreads systemically = Miliary TB OR in most infection is contained within granulomas but not dead = latent TB
Can latent TB be symptomatic?
No can only be asymptomatic
Symptoms of non-latent TB?
- Characteristic night sweats + weight loss - Pyrexia, chest pain and patient will look unwell - Extrapulmonary: - Meningitis (meningism + fever) - Skin changes - TB pericarditis symptoms - Joint pain
Investigations to diagnose TB?
- Mantoux skin (tuberculin) test - to ID latent or active TB - Sputum culture 3x +ve = acid fast bacilli, bright red w/ Ziehl Nielsen - CXR - Biopsy
Treatment of TB?
RIPE: 2266 Rifampicin - 2 months, SE: haematuria Isoniazid - 2 months, SE: peripheral neuropathy (tingly hands/feet) Pyrimidine - 6 months, SE: hepatitis Ethambutol - 6 months, SE: eye problems (optic neuritis)
What are Interstitial lung diseases?
Group of chronic lung disorders characterised by inflammation and scarring that make it hard for lungs to get enough oxygen
Give the 6 types of chronic ILDs and examples
1) granulomatous = sarcoidosis 2) Inhalational = hypersensitivity pneumonitis, pneumoconiosis 3) Idiopathic pneumonias = pulmonary fibrosis + Non-pulmonary fibrosis 4) connective tissue = scleroderma, RA 5) Drug induced = amiodarone, bleomycin 6) Other = Goodpasture’s, vasculitis
Most common interstitial lung disease?
Pulmonary Fibrosis
Who is pulmonary fibrosis most commonly seen in?
- Older men 60+ - Smoke
Cause for pulmonary fibrosis?
Often Idiopathic
Risk factors for pulmonary fibrosis?
smoking - occupational (eg. Dust) - Drugs (methotrexate) - Viruses (EBV, CMV)
Pathophysiology for pulmonary fibrosis?
Pulmonary fibrosis (progressive scarring) —> T1 respiratory failure
Symptoms of pulmonary fibrosis?
Exertional dysponea - dry unproductive Cough
Investigations to diagnose pulmonary fibrosis?
- Spirometry = restriction - FEV: FVC >0.7 BUT FVC decreased (<0.8 normal) - Gold standard = High res CT (chest) = GROUND GLASS lungs + traction bronchiectasis
Treatment for pulmonary fibrosis?
smoking cessation + vaccines - Pirfenidone, Nintendinib - surgery (lung transplant)
How is pmeumoconiosis acquired?
Occupationally acquired
Two causes of pneumoconiosis?
Silicosis - Asbestosis
What is silicosis?
Inhalation of silicon dioxide, egg shell calcification at hilar lymph nodes
What is asbestosis?
Inhalation of asbestos which affects pleura - causes mesothelioma and T1 respiratory failure
What is Sarcoidosis?
Idiopathic granulomatous disease
Risk factors for sarcoidosis?
- Women - 20-40yrs old - Afro Caribbean
Symptoms of sarcoidosis?
- Fever - Fatigue - Respiratory: dry cough, dysponoea - Other: eye lesions (uveitis), lupus pernio (blue- red nodules in nose + cheeks)
Investigations to diagnose sarcoidosis?
- CXR (staging 1-4) shows bilateral hilar adenoathy + pulmonary infiltrates - Diagnostic = biopsy shows non caseating granuloma Also increase in serum calcium and serum ACE (granulomas)
Name a subset of sarcoidosis?
lofgrens syndrome (systemic acute sarcoidsis)
Symptoms of Iofgren’s syndrome?
Triad of: 1) acute polyarthiritis 2) erythema nodosum 3) bilateral hilar adenopathy
Treatment for Sarcoidosis?
Early stages = self resolving Symptomatic patients = corticosteroids
What is hypersensitivity pneumonitis?
T3 hypersensitivity: - immune (Ab-Ag) complex deposition at lung tissues - causes immune hyperresponse
Risk factors for hypersensitivity pneumonitis?
Occupation (e.g farming) - Bird keeping
Most common type of hypersensitivity pneumonitis?
Farmer’s Lung - due to mouldy hay
5 types of hypersensitivity pneumonitis?
- Farmer’s lung - mouldy hay - Pigeon fancier’s lung - avian protein, bird droppings - Malt workers lung - Cheese workers lung - Humidifier fever
Treatment for hypersensitivity pneumonitis?
Remove allergen
What is Goodpasture’s syndrome?
T2 autoimmune hypersensitivity response
Pathophysiology of Goodpasture’s?
- presence of autoantibodies to the alpha-3 chain of type IV collagen - anti Glomerular basement membrane disease (anti-GBM) - attack lungs + kidneys = lung fibrosis + glomerulonephritis
Investigations to diagnose Goodpasture’s?
1) Lung + kidney biopsy = damage + Ig deposition 2) Serology = anti-GBM +ve (anti glomerular basement membrane)
Treatment for Goodpasture’s?
1) Supportive, 2) Corticosteroids 3) Plasma exchange (get rid of anti GBMs antibodies)
Another name for Wegener’s granulomatosis?
Granulomatosis with polyangiitis
What is Wegener’s granulomatosis?
Granulomatosis vasculitis affecting small and medium vessels - typically causes ENT, lung and kidney symptoms
What is associated with Wegener’s granulomatosis?
C-ANCA vasculitis
Symptoms of Wegener’s granulomatosis?
ENT = saddle shaped nose, ear infection Lungs = diffuse alveolar haemorrhage => haemoptysis Kidney = glomerulonephritis => haematuria
Investigations to diagnose Wegener’s granulomatosis?
c-ANCA +ve
Differential diagnosis for Wegener’s granulomatosis?
1) Microscopic polyangiitis (MPA) 2) Eosinophilic granulomatosis with polyangiitis (EGPA) but these are both mostly p ANCA positive
Treatment for Wegener’s granulomatosis?
Corticosteroids - Immunosuppression e,g Rituximab
What is bronchiectasis?
Permanent dilation of bronchioles - Excessive mucus in them
Which lobes does bronchiectasis usually effect?
Usually effects lower lobes
Symptoms of bronchiectasis?
Productive cough with lots of sputum and dyspnoea
Risk factors for bronchiectasis?
most Commonly occurs post infection e.g TB, Pneumonia - CF - HIV - ABPA (Allergic bronchopulmonary aspergillosis)
Pathophysiology of bronchiectasis?
- Irreversible dilation - Loss of cilia - Mucus hypersecretion - ↑increased risk of infection (as decreased muco-cilliary clearance)
Investigations to diagnose bronchiectasis?
Imaging: - CXR - HRCT (Gold standard) - dilated thickened bronchi (signet ring sign) - cysts at the end of bronchioles Spirometry = obstructive - FEV1:FVC <0.7 - Sputum culture (check infection)
Infective organisms that can cause bronchiectasis and treatment?
H.Influenzae - S.pneumoniae - P.aeruginosa Use antibiotics eg. amoxicillin
Treatment of bronchiectasis?
Non curative *conservative - Chest physio + smoking cessation *drug - bronchodilators to manage symptoms consider antibiotics If infection
What is Cystic Fibrosis?
- Auto recessive mutation on chromosome 7 - Changes f508 gene which codes for CFTR Protein
Risk factors for cystic fibrosis?
Family History - Caucasians
Pathophysiology of Cystic fibrosis?
Defective CFTR gene - Normally secretes CL- actively & Na+ passively (+H20) into ductal secretions making them thin + watery => With defective gene, ductal secretions are thicker with increased Na+ and Cl- retention
What happens to the lungs in CF?
Impaired mucocilliary clearance as mucus extra thick ↑stagnation = ↑infection risk and difficulty breathing and ↑risk of bronchiectasis
When is CF mostly diagnosed?
In childhood (90% before 8 y/o)
Symptoms of CF?
- Resp: thick + sticky sputum cough, recurrent upper respiratory tract infection, bronchiectasis GIT: thick secretions, pancreatic insufficiency, bowel obstruction Other : - males = atrophy of vas deferens + epididymis - very salty sweat
Symptoms of CF in neonates?
Meconium ileus (bowel obstruction Due to earliest stool being too thick to pass through) - failure to thrive
Investigations to diagnose CF?
- Sweat test (Na+ and Cl- >60mmol/L in children) - Faecal elastase -ve/↓ (= obstruction as normally elastase produced by pancreas + found in faeces) - fHx, genetic testing (mutation in f508)
Common infections in CF patients?
S.Aureus - H.Influenzae - P.aeroginosa (same as bronchiectasis)
Treatment for CF?
Non curative - Conservative -> chest physio, no smoking - Drugs -> anti mucolytic, bronchodilator, pancreatic enzyme replacements + fat soluble vitamin supplements
What is pleural effusion?
Excess fluid accumulation between visceral + parietal pleura layers
How is fluid in pleural effusion categorised?
Fluid is either: 1) Transudative 2) Exudative
What is transudative fluid?
↓Protein; <25 g/L - Due to ↑increased hydrostatic pressure or ↓oncotic pressure - TRANSparent fluid E.g congestive heart failure, liver cirrhosis, nephrotic syndrome
What is exudative fluid?
↑Protein; >35g/L - Due to inflammation causing ↑vascular permeability - Cloudy e.g cancer, TB, pneumonia
What is the Light’s criteria?
Used to determine if fluid is exudative when protein is 25-35g/L and therefore in the grey area
Symptoms of Pleural effusion?
Generic: dyspnoea, pleuritic chest pain, cough, ↓breathing sounds - Dull percussion (↑increased fluid) on ipsilateral side
Differential diagnosis for pleural effusion?
Pneumothorax however this has a hyper resonant sound when listened to, not dull percussion on ipsilateral side
Investigations to diagnose Pleural effusion?
GS + 1st line: CXR = ↓costophrenic angles (‘blunting’) - excess fluid appears white +/- tracheal deviation Thoracentesis = aspiration of pleural fluid - tells us pH, lactate, WCC, trans or exudate
Treatment of Pleural effusion?
Chest drain - If recurrent = pleurodesis - surgical fusing of pleural layers to prevent Fluid build up
What is Pneumothorax?
Excess air accumulation in pleural space => causing ipsilateral collapse of lung
Typical pneumothorax patient?
Tall thin males with connective tissue disorders (marfan’s, ED) +/- smokers, with some kind of trauma
Types of pneumothorax?
Primary (spontaneously with no underlying cause) - Secondary (to a trauma or pathology)
Pathophysiology of Pneumothorax?
pleural space Normally a vacuum - Breach in pleura ( Due to trauma or conn. tissue disorder) e.g subpleural bullae burst = abnormal connection between pleural space + airways (fistula)
Symptoms of pneumothorax?
SOB - One sided sharp pleuritic Chest pain - decreased breathing sounds - Hyper resonant percussion ipsilaterally (Due to Increased air)
Two types of pneumothorax?
1) Simple pneumothorax 2) Tension pneumothorax
Differences between simple and tension pneumothorax?
Simple: - Non medical emergency, little tracheal deviation - Air can flow in/out of valve between alveoli + pleura => Unlikely to worsen with every breath Tension: - Medical emergency with contralateral tracheal deviation - One way valve (air into pleural space, not out) => worsens with each breath
Investigations to diagnose pneumothorax?
Gold standard + 1st line:CXR = Excess fluid appears black + Tracheal deviation to other side * CT is more sensitive so useful in detecting smaller pneumothoraxes
Treatment for smaller pneumothoraxes?
Self healing
Treatment for larger pneumothorax?
Needle Compression (suck air out with a syringe) + Chest drain (One way air removal, air can only leave so longer term treatment) surgical treatment If its recurrent = pleurodesis
What to do if tension pneumothorax is obvious?
Avoid chest xray and go straight to treatment
Treatment for tension pneumothorax?
Insert large bore cannula into 2nd intercostal space at midclavicular line - needle decompression first and then chest drain
What is Cor Pulomonale?
Right ventricle enlargement due to long term pulmonary (artery) hypertension => Leads to right heart failure
What is pulmonary hypertension?
resting mPAP >25mmHg measured with heart catheterisation
What does pulmonary hypertension often result in?
RHS heart failure (cor pulomonale)
Causes of pulmonary hypertension categorised?
Pre capillary = pulmonary emboli, Primary pulmonary hypertension - capillary + lung = COPD, asthma - post capillary = LV failure - Chronic hypoxemia = COPD, altitude
Pathophysiology of pulmonary hypertension?
- Reactive pulmonary vasocontriction when hypoxic -> ↑increased vascular resistance and pressure => thus endothelial damage -> RVH + (right heart) failure
How does a patient present with pulmonary hypertension?
Initially = exertional dyspnoea and fatigue Then right heart failure signs
Signs of right heart failure?
Increased JVP - peripheral oedema - v waves prominent on JVP - louder S2 than normal
Investigations to diagnose pulmonary hypertension?
CXR = RVH, enlarged proximal pulmonary artery ECG = RA dilation (p.pulmonary, peaked P waves > 2.5mm) ECHO = RVH Diagnostic (GS) = right heart catheter (>25mmHg)
Treatment for pulmonary hypertension?
- Phosphodiesterase-5 inhibitor (sildeiaful = viagra). - CCB (amlodipine) - Endothelin-1-antagonists/prostagladin analogues - Diuretics for oedema
What is pharyngitis?
Inflammtion of pharynx +/- exudate
Causes of pharyngitis?
Viral - EBV, adenoviruses Bacterial - group A beta haemolytic strep = s.pyogenes
Bacteria that often causes otitis media and pharyngitis?
Streptococci => treatment is amoxicillin - aka flucloxacillin
Symptoms of pharyngitis?
Sore throat + fever If viral = + cough + nasal congestion If bacterial = + exudate
What disease should be ruled out when considering pharyngitis?
Rheumatic Fever - especially in children if bacterial
What is rheumatic fever?
Systemic inflammatory disease - typically 2-4 weeks post group A strep infection
What is sinusitis?
Inflamed mucosa of nasal cavity + nasal sinuses
Cause of sinusitis?
- Mostly viral causes (<10 days non purulent discharge) - Sometimes bacterial (>10 days, purulent)
Bacterial causes of sinusitis and prevalence?
S.Pneumo (40%) H.Influenzae (30%) (self limiting)
Treatment for bacterial causes of sinusitis?
Amoxicillin
What is Otitis media?
Inflamed middle ear - typically in children
Cause if otitis media?
Bacterial or viral
Investigations to diagnose otitis media?
Otoscopy shows inflamed erythrmatous tympanic membrane
What can sinusitis and Otitis media be linked too?
Meningitis contagious spread (direct to meninges, not through blood)
What is epiglottitis?
Inflammation of epiglottis = obstructs airways = Mostly occurs in kids under 5
Most common cause of epiglottitis?
H.influenzae
Symptoms of epiglottitis?
- TRIPODING (leant forward, mouth open, tongue out = max air in) - Sore throat - SOB
Investigations to diagnose epiglottitis?
Gold standard= laryngoscopy XR = lateral radiograph => thumb print sign
What is whooping cough?
Chronic cough caused by bordella pertussis (gram -ve bacilli) - Mainly in children
Prevalence of whooping cough
90% of case under 5 years old
Pathophysiology of whooping cough?
↑bordella virulence - Haemagglutinin + fimbrae adhere to URT - Adenylate cyclase toxin inhibits phagocyte chemotaxis - Perctussis toxin inhibits alveolar macrophages
Symptoms of whooping cough?
Characteristic violent cough
What is croup/laryngobronchitis?
Occasional complication of URTI particularly from parainfluenza + measles infection (children <3y/o)
Symptoms of Croup/laryngobronchitis?
Hoarse voice + barking Cough (Croup) - Stridor (high pitched Wheeze when inhaling)
Treatment for croup/laryngobronchitis?
Single dose dexamethasone
What does type 1 respiratory failure entail?
Normal pCO2 with low pO2 indicates type 1 respiratory failure (only one is affected) (low PO2 indicates hypoxia and respiratory failure)
What does type 2 respiratory failure entail?
Raised pCO2 with low pO2 indicates type 2 respiratory failure (two are affected)
if there has been compensation in acidosis/alkalosis, is it acute or non acute?
Non acute -acute doesn’t occur with compensatory mechanisms
What does an ABG tell us in terms of resp system?
Resp failure = acute or chronic
