Respiratory Flashcards
severity of ARDS
depends on hypoxaemia
mild: PaO2 > 200
mod: PaO2 100-200
severe: PaO2 < 100
actions of alpha 1 antitrypsin
defends against neutrophil elastase
types of asbestos lung disease
pleural plaques
pleural thickening (mostly at bases, restriction and reduced compliance, reduced total lung capcity, normal KCO)
pleural effusions (often spontaneously resolve, usually exudate)
asbestosis
lung ca
treatment of mesothelioma
talc or indwelling pleural catheters for symptomatic effusion
RTx, CTx (non curative)
surgery potentially curative
hard metal lung disease
caused by cobalt dust
from making cutting tools or jet engine parts
> fibrosis
multi nucleated giant cells in alveoli with granulomas
Aspergillus species
over 200
Aspergillus fumigatus causes 70% aspergillosis
A terreus resistant to amphoteracin B and has poor prognosis
Aspergillosis disease patterns
- invasive
- ABPA
- chronic pulmonary aspergillosis (CPA)
- isolated infection
invasive aspergillosis
spores germinate into hyphae in immunocompromised
> invade parenchyma
> inflammation, thrombosis, infarction)
> haematogenous dissemination to brain, skin, eyes, heart, kidney, liver, spleen, GI , bone
ABPA
hypersensitivity to antigens from Aspergillus
typically CF and asthma pts
type I and type III
bronchiectasis and airway obstruction
chronic pulmonary aspergillosis
destructive infection
> fibrosis and loss of lung tissue
aspergilloma (assoc w/ TB)
aspergillus nodule
chronic cavitary (usually immunocompetent)
chronic necrotising (assoc with COPD and ETOHXS)
aspergillus isolated infection
nails, eyes, skin, sinuses, ear canals
endocarditis
endophthalmitis
diagnosing invasive aspergillosis
positive serum aspergillus galactomannan
serum 1-3 beta D glucan (not specific for aspergillus)
PCR RNA
HRCT chest
HRCT or MRI sinuses, brain
ABPA diagnosis
total IgE antibodies
aspergillus specific IgE and IgG
positive weal and flare skin test
eosinophilia
CXR infiltrates, bronchiectasis
HRCT mucoid plugging, infiltrates and bronchiectasis
chronic pulmonary aspergillosis diagnosis
IgG
CXR and HRCT- upper lobe mobile mass with air crescent, multiple nodules and cavities
treating invasive aspergillosis
amphoteracin B or echinocandin (caspofungin)
colony stimulating factors
isavuconazole, voriconazole 3/12
prophylaxis posaconazole
surgery if lesions continuous with great vessels of pericardium or severe haemoptysis from single cavity
asthma lung function tests
increased volume, reduced FEV1 and FEV1: FVC ratio < 70%
variable PEFR > 20%
improved PEFR > 15% after bronchodilator or steroids
berylliosis
looks similar to sarcoid
non caseating granulomas in lungs and nodes
surrounding fibrous tissue
CXR: fine nodulation evenly distributed throughout and b/l hilar lymphadenopathy
> progressive SOB and RHF
causes of bronchiectasis
LRTI
idiopathic
Marfans, Williams Campbell
HIV, haem malignancy, post transplant
RA, sjogren
IBD
ABPA, CF
obstructed or compressed bronchus (malignancy)
chemical pneumonitis
primary ciliary dyskinesis, kartagener, young
A1AT
asthma management
SABA for everyone
add ICS
> add LRTA or LAMA
COPD management
- SABA or SAMA
2a. (no asthma/steroid responsiveness) LABA + LAMA
2b. LABA + ICS - LABA + LAMA + ICS
remove ICS if it is not helping
indications for transplant in COPD
< 65y and:
- FEV1 and DLCO < 20% predicted
- history of hospitalisation w/ acute hypercapnia
- pulmonary HTN and/or cor pulmonale despite oxygen therapy
assessing COPD prognosis
BODE for 2y mortality
BMI, airflow Obstruction, Dyspnoea, Exercise
Decaf for inpatient mortality
Dyspnoea, Eosinophils < 0.05, Consolidation, Acidaemia, AF
simple vs progressive coal workers pneumoconiosis
simple:
small, asymptomatic round opacities
upper zones
focal emphysema
progressive:
nodule aggregation into larger opacities
possible cavitating lesions
Caplan syndrome
multiple round nodules in patients with seropositive RA with coal workers pneumoconiosis
in peripheral crops
myocoplasma pneumonia
occurs in 3-4 yearly epidemics
> 2 week prodrome
peri/myocarditis
erythema multiforme, nodosum, SJS
haemolytic anaemia, DIC, thrombocytopaenia
meningoencephalitis, neuopathies
bullous myringitis
hepatitis, pancreatitis
Horders spots
rose spots on face
associated with psittacosis
CURB 65
confusion
RR > 30
SBP < 90 or DBP < 60
age > 65y
admit if 3 or more
legionella length of treatment
21 days
CF colonisation
children: staph then haemophilus
adolescents: pseudomonas
CF drug management
inhaled bronchodilator and ICS
rhDNase mucoactive agent
tobramycin for chronic pseudomonas
azithromycin, ibuprofen, pred
fluclox as staph prophylaxis for under 3ys
CFTR modulator ivacaftor
pancreatin, fat soluble vits ADEK
lung transplants absolute contraindications
Burkholderia cepacia colonisation
sepsis
multi organ dysfunction
non adherence to tx
morbid obesity
refractory GORD
eosinophilic granulomatosis with polyangiitis lung biopsy
necrotising granulomas with central eosinophilic core and necrotising vasculitis
hypersensitivity pneumonitis
Th-1 mechanism
IgG mediated
acute- symptoms appear within hours of high level exposure and resolve within 48h, no fibrosis
chronic- gradual after prolonged low level exposure
can develop into fibrosis or emphysema
biopsy: mononuclear infiltrate, non caseating granulomas
reversible if diagnosed early
drugs causing fibrosis
amiodarone
sulfasalazine, MTX
bisulfan, bleomycin
cyclophosphamide
nitrofurantoin
gold
melphalan
lambert eaton treatment
3, 4 diaminopyridine
or pyridostigmine
gynaecomastia is associated with what lung cancer?
large cell and adenocarcinoma
hyperthyroid is associated with what lung cancer?
squamous
SCLC paraneoplastic syndromes
SIADH
ectopic ACTH
Lambert Eaton (weakness IMPROVES with repeated contraction)
HPOA
hypertrophic pulm osteoarthropathy
assoc w/ adrenocardinoma
periostitis, arthritis, clubbing
pancoast
non SCLC
superior sulcus
hand atrophy, horners
lung transplant donor criteria
< 55y
ABO compatible
clear CXR
pao2 > 300
< 20 pack years
no chest trauma, aspiration, sepsis or prior cardiopulm surgery
no organisms on gram stain
no purulent secretions at bronchoscopy
mesothelioma staging
1a. ipsilateral partietal pleura
1b. visceral pleural involvement
2. diaphragm or lung involvement
3. any locally advanced or nodes N1 or N2
4. locally advanced unresectable, N3 (contralateral nodes or internal mammary or supraclavicular nodes)
byssinosis
occupational lung disease from cotton dust, flax, hemp
acute or chronic
PE extra heart sounds
TR murmur
widely split S2
PE admission criteria
haemodynamic instability
pregnant or postpartum
level 2 Wells > 4
contraindications to DOAC for PE
active cancer
renal impairment
antiphospholipid syndrome
haemodynamic instability
> LMWH at least 5/7
dabigatran/edoxaban or warfarin
pulmonary HTN WHO groups
- pHTN
- pHTN + left heart disease
- pHTN + lung disease/hypoxaemia
- pHTN + chronic thrombotic/embolic disease
- pHTN + disorders directly affecting pulm vasculature (schisto, sarcoid, glycogen storage)
pHTN treatment
anticoagulation
digoxin
PGI2 continuous IV infusion while a/w transplant
PDE5i
bosentan
CCB
pulm endarterectomy
balloon pulm angioplasty
atrial septostomy
heart lung transplant
pulmonary TB in HIV patients
consolidation, miliary, effusions
cavitation is less common
PCP prophylaxis
cotrimoxazole
for pt with CD4 < 200
for pt with previous PCP
normal mean pulmonary arterial pressure
15-30 mmHg
chemoreceptors involved in respiration
central:
on ventral medulla
respond to H+ from CO2
peripheral:
carotid bodies and aortic bodies
respond to hypoxaemia, hypercapnia, pH
Lofgren syndrome
bilateral hilar lymphadenopathy + erythema nodosum
+ fever + arthralgia
sarcoid CXR grading
0: clear
1: BHL
2: BHL + pulmonary infiltrates
3: diffuse pulmonary infiltration
4: fibrosis
silicosis
quarry workers, hard rock miners, ceramic manufacturers, AKA Potter’s Rot
increased risk of CTD, vasculitis, CKD
many have polyclonal hypergammaglobulinaemia, rheum factor, ANA, immune complexes
acute:
weeks-5y from exposure
involves v high levels of dust
accelerated:
5-15y latency
high levels of silica
can progress after removal of source
simple chronic:
most common, low level exposure
20y latency
risk of progressive massive fibrosis
silicosis investigation and treatment
CXR: non calcified round opacities in upper zones similar to coal pneumoconiosis
egg shell calcification around enlarged hilar glands
> bronchodilators if also COPD
> lavage if acute
> transplant
how to prevent peripheral neuropathy with anti TB treatment
risk from isoniazid
give pyridoxine for people with ETOHXS, diabetes, renal failure
indications for mechanical ventilation
severe hypoxaemia < 8.3 kpa despite 0.6 FiO2
PaCO2 > 6kpa
