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Phase 4 Question Knowledge > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Asthma

A
  • chronic reversible obstructive airway disease -> inflammation / bronchospasm
  • non/eosinophilic
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2
Q

Asthma RFs

A
  • atopy
  • maternal smoking, low birth weight, formula fed
  • air pollution
  • allergens, eg dust mites

Triggers

  • infection, nighttime, exercise, animals, cold/damp air, strong emotions

Occupational

  • workplace triggers - eg flour…
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3
Q

Asthma Px

A
  • episodic sx
  • diurnal variation - worse at night
  • SOB
  • chest tightness
  • dry cough
  • wheeze - widespread, polyphonic
  • reduced PEFR
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4
Q

Asthma Ix

A

Measure eosinophil count or fractional nitric oxide (FeNO)

Diagnose asthma, without further investigations if:
Eosinophil is above reference range
FeNO is ≥ 50 ppb

If asthma is not confirmed by the eosinophil count or FeNO
measure bronchodilator reversibility (BDR) with spirometry
diagnose asthma if:
the FEV1 increase is ≥ 12% and 200 ml or more from the pre-bronchodilator measurement, or
the FEV1 increase is ≥ 10% of the predicted normal FEV1
if spirometry is not available or it is delayed, measure peak expiratory flow (PEF) twice daily for 2 weeks
diagnose asthma if:
PEF variability (expressed as amplitude percentage mean) is ≥ 20%

If asthma is not confirmed by eosinophil count, FeNO, BDR or PEF variability but still suspected on clinical grounds:
refer for consideration of a bronchial challenge test
diagnose asthma if bronchial hyper-responsiveness is present

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5
Q

Asthma Dx

A

Initial Ix

  • FeNO
  • spirometry with bronchodilator reversibility

If dx uncertain

  • peak flow diary

If still uncertain

  • direct bronchial challenge
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6
Q

Asthma new joint guidelines

A

Step 1: a low-dose inhaled cordicosteroid (ICS)/formoterol inhaler to be taken as needed for symptom relief (anti-inflammatory reliever (AIR) therappy
If the patients presents highly symptomatic or with a severe exacerbatiion-
Start treatment with low-dose MART
Treat the acute symptoms as appropriate (a course of oral corticosteroids may be indicated)

Step 2:
A low dose MART- (ICS/formoterol combination for maintenance therpay as needed ie regularly and as required)

Step 3:
A moderate-dose MART

Step 4:
Check the fractional exhaled nitric oxide (FeNO) level if available, and the blood eosinophil count-
If either raised- specialist case
If neither raised- trial LTRA or a LAMA in addition to MART
If control has not improved stop LTRA or LAMA and start the alternative (LTRA or LAMA)

Step 5-
Reder people to a specialist in asthma care when asthma is not controlled despite treatment with moderate-dose MART, and trials of an LTRA and a LAMA

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7
Q

Asthma further Mx

A
  • ?occupational - refer to resp
  • yearly flu jab
  • yearly asthma review
  • consider stepping down tx every 3mo or so
  • reducing ICS dose - only by 25-30% at a time
  • regular exercise, avoid smoking, avoid triggers
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8
Q

Asthma drugs

A

SABA - salbutamol

LABA - salmeterol, formoterol

SAMA - ipratropium

LAMA - tiotropium

ICS - beclometasone / budesonide

MART - Fostair - beclometasone + formoterol

Trimbow - beclometasone + formoterol + glycopyrronium

LTRA - montelukast

Theophylline

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9
Q

Acute exacerbation of asthma

A
  • rapid deterioration in sx in asthma
  • triggers as chronic, may be infection
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10
Q

Acute asthma Px

A
  • SOB
  • Cough
  • Accessory muscle use
  • Tachypnoea
  • Global wheeze
  • Reduced air entry
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11
Q

Acute asthma grading

A

Moderate

  • PEF 50-75%

Acute severe

  • PEF 33-50% best
  • RR>25
  • HR>110
  • Unable to complete sentences

Life-threatening

  • PEF <33%
  • Sats <92%
  • Silent chest, cyanosis
  • Bradycardia, low BP
  • Exhaustion, confusion, coma

(Near fatal)

  • Raised pCO2
  • mechanical ventilation, raised inflation pressures
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12
Q

Acute asthma Ix

A
  • ABG - resp alkalosis -> hypoxic -> normal pCO2
  • bloods, CXR
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13
Q

Acute asthma admit if

A
  • Life-threatening grade
  • Acute severe grade + unresponsive to tx
  • Previous near-fatal attack
  • Pregnancy
  • Occurring despite oral corticosteroid
  • Px at night
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14
Q

Acute asthma Mx

A
  • abx
  • O2
  • salbutamol - inhaler / nebs
  • PO prednisolone 40-50mg / IV hydrocortisone 5d (3d in paeds)
  • ipratropium - nebs
  • IV Mg
  • IV salbutamol
  • IV aminophylline
  • Intubation/ventilation, ECMO
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15
Q

Acute asthma criteria for discharge

A
  • Stable on discharge medication (no nebs / O2) for 12-24hrs
  • Inhaler technique checked + recorded
  • PEF >75%
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16
Q

COPD

A
  • Chronic irreversible progressive condition involving airway obstruction, emphysema, chronic bronchitis

Causes

  • smoking, A1AT deficiency, coal, cotton, cement…
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17
Q

COPD Patho

A
  • bronchitis - airway inflammation, fibrosis, mucus production
  • emphysema - parenchymal destruction, loss of elastic recoil, reduced SA for gas exchange
  • V/Q mismatch, lack of oxygenation, CO2 retention
  • increased pulmonary artery pressure -> PAH, RHF
  • some pts CO2 retainers
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18
Q

COPD Px

A
  • SOB, cough, sputum, wheeze
  • recurrent infections
  • minimal diurnal variation
  • accessory muscles
  • hyperinflation
  • decreased cricosternal distance
  • decreased expansion, hyperresonant
  • pursed lips
  • cyanosis, cachexia
  • cor pulmonale - peripheral oedema, raised JVP, SOBOE, syncope, chest pain
  • PP/BB
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19
Q

MRC SOB scale

A
  1. SOB on marked exertion
  2. SOB on hills
  3. Slow or stop on flat
  4. Exercise tolerance 100-200 yards on flat
  5. Housebound / SOB on minor tasks
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20
Q

COPD vs asthma

A
  • Younger onset in asthma
  • Smoking - in most with COPD
  • Asthma - sx vary, less so in COPD
  • Nocturnal sx in asthma
  • Persistent productive cough - COPD
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21
Q

COPD Ix

A
  • spirometry - FEV1/FVC<70%
  • CXR - hyperinflation, flat hemidiaphragms, bullae
  • FBC - anaemia/polycythaemia
  • ECG / ECHO
  • CT thorax
  • transfer factor for CO (TLCO)
  • ?A1AT levels
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22
Q

COPD severity

A

Stage 1 / mild - FEV1>80%
Stage 2 / moderate - FEV1 50-79%
Stage 3 / severe - FEV1 30-49%
Stage 4 - very severe - FEV1 <30%

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23
Q

COPD Mx

A
  • stop smoking, pneumococcal/flu jabs
  • pulm rehab
  • inhalers
  • oral theophylline
  • prophylactic abx - azithromycin
  • mucolytics
  • PDE-4 inhibitors - roflumilast
  • furosemide for cor pulmonale
  • LTOT - long-term O2 therapy
  • surgery - lung volume reduction surgery, bullectomy, lung transplant
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24
Q

COPD Inhaler Mx

A

1st step

  • SABA / SAMA

2nd step

Asthma/steroid-responsive features

  • previous dx asthma/atopy
  • variation FEV1 >400mls
  • diurnal variation PEF >20%
  • raised eosinophils
  • if no features -> LABA + LAMA (anoro ellipta)
  • if features - LABA + ICS (fostair)

3rd step

  • LABA + LAMA + ICS (trimbow)
  • do not prescribe LAMA with SAMA (change to SABA)
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25
Q

Long term O2 therapy

A

Assess by measuring 2 ABGs >3wks apart in stable COPD pts on optimum mx, carry out if

  • FEV1<30%, cyanosis, polycythaemia, peripheral oedema, raised JVP, sats <92%

Indication

Offer LTOT if pO2 <7.3, or pO2 7.3-8 and any of:

  • secondary polycythaemia
  • peripheral oedema
  • PAH
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26
Q

COPD Cx

A
  • acute exacerbation, resp failure
  • secondary polycythaemia
  • PAH, cor pulmonale
  • PTX
  • lung ca
  • exercise limitation - reduced QoL
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27
Q

IECOPD

A
  • acute deterioration in sx in COPD pt

Causes

  • bacterial - H influenzae, strep pneumoniae, M catarrhalis
  • Viral - human rhinovirus
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28
Q

IECOPD Px

A
  • SOB, cough, wheeze
  • increased sputum
  • hypoxia, acute confusion
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29
Q

IECOPD Ix

A
  • Bloods - FBC, U/E, CRP, cultures
  • ABG - resp acidosis (raise bicarb indicates chronic retainer)
  • CXR
  • ECG
  • sputum culture
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30
Q

IECOPD admit if

A
  • Severe SOB
  • Acute confusion, impaired consciousness
  • Cyanosis
  • Low sats
  • Social reasons - eg unable to cope at home
  • Significant comorbidities
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31
Q

IECOPD Mx

A
  • O2
  • salbutamol / ipratropium
  • 30mg prednisolone for 5d / IV hydrocortisone
  • abx - amoxicillin / clarithromycin / doxycycline
  • chest physio

severe

  • IV aminophylline
  • NIV - biPAP
  • intubation / ventilation
  • doxapram
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32
Q

Pneumonia

A
  • infection of lung tissue - inflammation in alveolar space
  • inflammation + pus - impairs gas exchange
  • neutrophils - cytokines - inflammatory response + fever
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33
Q

Pneumonia types

A

CAP - community

HAP - >48hrs in hospital

VAP - intubated

Aspiration - form aspiration of foods/fluids

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34
Q

Pneumonia causes

A

Bacterial

  • Strep pneumoniae (most common), H influenzae (COPD)
  • Moraxella catarrhalis – COPD / immunocompromised
  • Pseudomonas aeruginosa – CF / bronchiectasis
  • S aureus – CF
  • MRSA – HAP
  • Klebsiella – alcoholics

Atypical - cannot be cultured in normal way

  • Legionella – air conditioning units, causes SIADH (hyponatraemia) – urine antigen test to screen
  • Mycoplasma pneumoniae – mild pneumonia, erythema multiforme rash – target lesions, neuro sx in young pts
  • Chlamydophila pneumoniae – mild chronic pneumonia + wheeze in school children
  • Coxiella burnetiid / Q fever – bodily fluids of animals – eg farmer
  • Chlamydia psittaci – contact with infected birds – eg parrot owner

Other

  • Pneumocystis jirovecii pneumonia (PCP) – immunocompromised, eg HIV with low CD4 – dry cough, SOBOE, night sweats, co-trimoxazole to tx
  • COVID-19
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35
Q

Pneumonia Px

A
  • cough, sputum +/- blood, SOB, fever, malaise, myalgia, pleuritic chest pain
  • delirium
  • dull to percussion
  • bronchial breath sounds
  • coarse focal crackles, reduced AE
  • raised RR, tachycardia, hypoxia, hypotension
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36
Q

CURB-65

A

C – confusion

U – urea >7mmol/L

R – resp rate >30

B – BP<90 systolic / 60 diastolic

65 – age >65yo

  • Score 0-1 – mild, consider home tx
  • Score 2– moderate, hospital admission
  • Score 3-5 – severe, admit, monitor, consider ITU
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37
Q

Pneumonia Ix

A
  • bloods - FBC, U/E, CRP, cultures, ABG
  • CXR - focal consolidation
  • sputum culture
  • pneumococcal / legionella urinary antigen tests
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38
Q

Pneumonia Mx

A
  • Abx - amoxicillin / doxy / clari / co-amox / IV / tazocin
  • O2
  • IV fluids
  • intubation / ventilation
  • rpt CXR in 6wks
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39
Q

Acute bronchitis

A
  • infection / inflammation of trachea/bronchi - viral often

Px

  • cough +/- sputum
  • sore throat
  • rhinorrhoea
  • wheeze
  • fever

DDx from pneumonia

  • may have no sputum/wheeze/SOB
  • no focal chest signs

Ix

  • clinical dx
  • bloods, CXR etc

Mx

  • doxy / amoxicillin
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40
Q

Aspiration pneumonia

A
  • inhalation of stomach contents/secretions, leading to URTI
  • chemical pneumonitis, obstruction of resp tract, bacterial infection
  • usually R lower/middle lobes

RFs

  • impaired GCS, swallowing disorder, poor mobility, older age, NBM, COPD

Mx

  • bronchoscopy - remove, send to MC+S
  • tracheal suction
  • intubation/ventilation
  • abx - amoxicillin/doxy/clari/erythro / co-amox/ levofloxacin
  • chest physio, bronchodilators, fluids
  • SALT referral
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41
Q

Lung cancer

A
  • cancer of lungs
  • 95% of primary are bronchial carcinomas
  • mets more common than primary - kidney, prostate, bone, GI tract, cervix, ovary
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42
Q

Lung cancer RFs

A
  • smoking, occupational (asbestos, coal, tar etc), radiation, pulm fibrosis, COPD
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43
Q

Lung cancer types

A

Small cell lung cancer (SCLC) - 20%

  • NE hormones released -> paraneoplastic

Non-small cell lung cancer (NSCLC) - 80%

  • adenocarcinoma - 40% - often seen in non-smokers
  • squamous cell - 20% - cavitating lesions
  • large cell - 10%
  • other - 10%
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44
Q

Lung cancer Px

A
  • SOB, cough, chest pain, haemoptysis
  • monophonic wheeze
  • finger clubbing
  • recurrent pneumonia
  • wt loss, lethargy
  • lymphadenopathy (supraclavicular)
  • mets - bone pain, headache, seizures, hepatic/abdo pain
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45
Q

Lung cancer extrapulmonary / paraneoplastic changes

A
  • Recurrent laryngeal nerve palsy - hoarse voice
  • Phrenic nerve palsy - SOB (diaphragm weakness)
  • SVC obstruction - facial swelling, difficulty breathing…
  • Horner’s syndrome - Pancoast tumour
  • SIADH - ectopic ADH from SCLC - hyponatraemia
  • Cushing’s syndrome - ectopic ACTH from SCLC - HTN, hyperglycaemia, hypokalaemia, alkalosis
  • Hypercalcaemia - ectopic PTH from SCC
  • Limbic encephalitis - SCLC causes immune system to produce ABs against limbic system - short-term memory impairment, hallucination, confusion, seizures
  • Lambert-Eaton myasthenic syndrome - ABs against SCLC also target Ca channels in presynaptic motor neurons
  • Gynaecomastia - AC
  • Hypertrophic pulmonary osteoarthropathy (HPOA) - AC / SCC
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46
Q

Lung cancer referral criteria

A

2ww for ?lung ca if
- CXR suggesting lung ca
- >40yo + unexplained haemoptysis

Offer urgent 2wk CXR in >40yo non-smoker and 2 of the following, or smoker and 1 of:
- Cough, fatigue, SOB, chest pain, weight loss, appetite loss

Consider urgent CXR if >40yo with
- Persistent / recurrent chest infection
- Finger clubbing
- Lymphadenopathy
- Chest signs of cancer
- Thrombocytosis

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47
Q

Lung cancer Ix

A
  • bloods
  • CXR - hilar enlargement, peripheral opacity, pleural effusion, collapse
  • CT TAP + contrast
  • bronchoscopy
  • PET scan - TNM
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48
Q

Lung cancer Mx

A

SCLC

  • chemo / radio
  • stents / debulking surgery
  • poor prognosis

NSCLC

  • surgery - segmentectomy/wedge resection, lobectomy, pneumonectomy
  • radiotherapy
  • chemo
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49
Q

Mesothelioma

A
  • Tumour of mesothelial cells - 80-90% in pleura - other sites are peritoneum, pericardium, testes
  • asbestos - 45yr latent period
  • high-grade, may invade intercostal nerves, severe pain
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50
Q

Mesothelioma Px

A
  • chest pain
  • SOB
  • wt loss
  • finger clubbing
  • recurrent pleural effusions
  • mets - lymphadenopathy, hepatomegaly, bone pain/tenderness, abdo pain/obstruction
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51
Q

Mesothelioma Ix

A
  • CXR/CT - unilateral pleural thickening/effusion
  • pleural aspiration - bloody
  • pleural biopsy
52
Q

Mesothelioma Mx

A
  • resistant to surgery/chemo/radio
  • palliative chemo
53
Q

PE

A

thrombus (blood clot) in pulmonary arteries
- venous thrombus, usually from DVT
- obstructs RV outflow - sudden increase in pulmonary vascular resistance - acute RHF
- lung tissue ventilated, not perfused - V/Q mismatch

54
Q

PE RFs

A
  • Immobility
  • Recent surgery
  • Long-haul flight
  • Pregnancy
  • Oestrogen therapy - cOCP, HRT
  • Malignancy
  • Polycythaemia
  • SLE
  • Thrombophilia
55
Q

VTE prophylaxis

A
  • Assess for VTE risk
  • LMWH (enoxaparin) if higher risk - CI - active bleeding, warfarin/DOAC
  • Anti-embolic compression stockings - CI - PAD
56
Q

PE Px

A
  • SOB
  • Cough
  • Haemoptysis
  • Pleuritic chest pain
  • Hypoxia
  • Tachycardia
  • Raised RR
  • Low-grade fever
  • Hypotension
  • May have DVT sx
57
Q

PE Ix

A
  • PERC rule
  • PE Wells score

If PE likely (>4)

CTPA

  • positive - dx
  • negative - consider leg USS

Delay to CTPA - interim DOAC/LMWH

PE unlikely (<4)

D dimer

  • positive - CTPA
  • negative - stop anticoagulation, alt dx

V/Q scanning - maybe if renal impairment

Other Ix

  • CXR - ?wedge-shaped opacification
  • ECG - S1Q3T3, RBBB, right axis deviation, sinus tachy
  • ABG - low O2/CO2
58
Q

PE Mx

A

Tx as outpatient if

  • stable, no comorbidities, support at home
  • Pulmonary Embolism Severity Index (PESI) score to stratify risk
  • O2, analgesia

Anticoagulation

  • DOAC - apixaban/rivaroxaban (1st line / active cancer)
  • LMWH, then dabigatran / edoxaban
  • LMWH, then warfarin
  • renal impairment - LMWH / heparin / LMWH then warfarin
  • APL - LMWH then warfarin

Anticoagulation length

  • all pts - 3mo
  • provoked - stop after 3mo (3-6mo if active cancer)
  • unprovoked - 6mo total
  • ORBIT score - assess bleeding risk

Unstable

  • thrombolysis - alteplase
  • surgical thrombectomy
  • IVC filter
59
Q

Pleural effusion

A
  • fluid in pleural space
  • empyema - pus
  • chylothorax - lymphatic fluid - trauma / carcinoma infiltration
60
Q

Pleural effusion causes

A

Transudative (<30g/L protein) – tend to be issue with flow

  • Heart failure (most common)
  • Hypoalbuminaemia - liver disease, nephrotic syndrome, malabsorption
  • Hypothyroidism
  • Meigs’ syndrome – benign ovarian tumour, pleural effusion, ascites

Exudative (>30g/L protein) – tend to be inflammation

  • Infection – pneumonia, TB, subphrenic abscess
  • RA, SLE
  • Neoplasia – lung ca, mesothelioma, mets
  • Pancreatitis
  • PE
  • Dressler’s syndrome
61
Q

Pleural effusion Px

A
  • SOB
  • Non-productive cough
  • Chest pain
  • Dull to percussion
  • Reduced breath sounds
  • Reduced chest expansion
  • Large effusion - tracheal deviation away from effusion
62
Q

Pleural effusion Ix

A
  • CXR - blunting of costophrenic angles, fluid in lung fissures, meniscus, tracheal deviation
  • USS
  • contrast CT
  • pleural aspiration - send for pH, protein, LDH, cytology, micro
63
Q

Pleural aspiration interpretation

A
  • Low glucose - RA, TB
  • Raised amylase - pancreatitis, oesophageal perf
  • Blood - mesothelioma, PE, TB
  • Empyema - pus, low pH, low glucose, high LDH
64
Q

Light’s criteria

A

Differentiate between transudate / exudate where protein 25-35. Exudate likely if at least one of the following is met:
- Pleural fluid protein / serum protein >0.5
- Pleural fluid LDH / serum LDH >0.6
- Pleural fluid LDH >2/3 upper limit normal of normal serum LDH

65
Q

Pleural effusion Mx

A
  • tx cause
  • pleural aspiration
  • chest drain

Empyema

  • chest drain
  • Abx

Recurrent

  • recurrent aspiration
  • pleurodesis
  • indwelling pleural catheter
  • opioids for SOB
66
Q

PTX

A
  • air in pleural cavity, can collapse lung
67
Q

PTX types

A

Primary spont PTX (PSP) - no underlying disease

Secondary spont PTX (SSP) - COPD, asthma, CF, cancer, PCP, Marfan’s

Traumatic - blunt / penetrating

Iatrogenic - eg thoracentesis, CVC, ventilation

Tension PTX - BP drops…

68
Q

PTX Px

A
  • sudden onset SOB
  • pleuritic CP
  • hyper-resonant
  • reduced AE
  • reduced chest expansion
  • tachypnoea, tachycardia
  • surgical emphysema
  • tension - resp distress, tracheal deviation, hypotension
69
Q

PTX Ix

A
  • CXR
  • CT chest
70
Q

PTX Mx

A

If no sx

  • conservative mx

If sx - assess for high risk characteristics

  • haemodynamic compromise
  • significant hypoxia
  • bl PTX
  • underlying lung disease
  • > 50yo, smoker
  • haemothorax

If high risk characteristics + safe to intervene (>2cm) -> seldinger chest drain

If no high risk - choice of intervention

  • conservative - IP/OP with clinic follow up
  • ambulatory device - Rocket Pleural vent
  • needle aspiration - if unsuccessful, then chest drain
71
Q

Persistent/recurrent PTX Mx

A
  • video-assisted thoracoscopic surgery (VATS) for mechanical / chemical (talc) pleurodesis +/- bullectomy / pleurectomy
72
Q

PTX discharge advice

A
  • avoid smoking
  • if ptx persists - cannot fly
  • avoid scuba diving - unless undergone bl surgical pleurectomy, normal PFTs/chest CT post-op
73
Q

Tension PTX Mx

A
  • needle decompression - 2nd ICS MCL, or 4/5th ICS just anterior to mid-axillary
  • then chest drain
74
Q

Bronchiectasis

A
  • permanent dilatation + thickening of bronchi after chronic inflammation
  • impaired mucociliary transport - chronic cough, excessive sputum, recurrent infections
  • main orgs - H influenzae, strep pneumoniae, S aureus, pseudomonas
75
Q

Bronchiectasis causes

A
  • post-infective - TB, measles, pertussis, pneumonia
  • CF
  • cancer/TB
  • immune deficiency
  • allergic bronchopulmonary aspergillosis
  • ciliary dyskinetic syndromes
  • yellow nail syndrome
76
Q

Bronchiectasis Px

A
  • persistent cough
  • sputum, purulent
  • SOB
  • intermittent haemoptysis
  • recurrent chest infections
  • coarse crackles / wheeze on auscultation
  • finger clubbing
  • wt loss
77
Q

Bronchiectasis Ix

A
  • sputum culture
  • CXR - tram-track opacities, ring shadows
  • HRCT - dilated/thickened bronchi, signet ring sign
  • spirometry - obstructive
  • bronchoscopy
78
Q

Bronchiectasis Mx

A
  • vaccines
  • chest physio, postural drainage
  • extended abx course for exacerbations (7-14d)
  • pseudomonas - cipro
  • H influenzae - amoxicillin, co-amox, doxy
  • S aureus - fluclox
  • long-term abx - azithromycin - if 3+ exacerbations/yr
  • bronchodilators
  • surgical resection
  • lung transplant
79
Q

Obstructive sleep apnoea (OSA)

A
  • collapse of pharyngeal airways whilst asleep leading to apnoeas
80
Q

OSA RFs

A
  • middle aged, male
  • obesity
  • alcohol
  • smoking
  • macroglossia
  • large tonsils
  • Marfan’s
81
Q

OSA Px

A
  • Partner may report excessive snoring, periods of apnoeas
  • Morning headache
  • Waking up unrefreshed from sleep
  • Daytime sleepiness
  • Concentration problems
  • Reduced O2 sats during sleep
  • Severe - HTN, HF, increased risk of MI / stroke
82
Q

OSA Ix

A
  • Epworth sleepiness scale
  • Multiple Sleep Latency Test (MSLT)
  • sleep studies (polysomnography)- diagnostic test
83
Q

OSA Mx

A
  • reduce alcohol, stop smoking, lose weight
  • CPAP
  • intra-oral devices - eg mandibular advancement
  • surgery - uvulopalatopharyngoplasty (UPPP)
  • inform DVLA if daytime sleepiness
84
Q

Occupational lung disorders

A

Inhaling something at work, leads to:
- acute bronchitis, oedema
- Pulmonary fibrosis
- Occupational asthma
- Hypersensitivity pneumonitis
- Bronchial carcinoma

85
Q

Occupational asthma

A
  • asthma sx worse at work
  • peak flow diary to compare work/home
86
Q

Pneumoconiosis

A
  • inhalation of coal dust, fibrosis occurs
  • coal mine workers -> coal-workers pneumoconiosis (CWP)
  • particles ingested by alveolar macrophages - die, release enzymes, cause fibrosis
  • simple pneumoconiosis / progressive massive fibrosis (PMF)
87
Q

Silicosis

A
  • inhalation of silica particles - fibrogenic
  • upper zone fibrosis, egg-shell calcification of hilar lymph nodes
  • eg stonemasons, sandblasters, pottery
  • massive airways restriction
88
Q

Asbestos and the lung

A

Pleural plaques

  • benign
  • discrete fibrous / partially calcified thickened area

Pleural thickening

  • extensive thickening of pleura - fibrosis
  • can lead to restrictive lung disease

Asbestosis

  • lung fibrosis from asbestos exposure - an ILD
  • Px - SOB, clubbing, bl end-insp crackles, restrictive

Mesothelioma

Lung cancer

  • most common form of cancer from asbestos exposure
89
Q

Byssinosis

A
  • inhalation of textile fibre dust
  • chest tightness, cough, SOB
  • Sx worse first day back at work after break
90
Q

Berylliosis

A
  • inhalation of copper alloy
  • aerospace, electrical devices
  • progressive SOB, pulm fibrosis
91
Q

Pulmonary siderosis

A
  • inhalation of metallic particles - metal grinding, welding
  • little effect on lung function
92
Q

Pulmonary fibrosis

A
  • diseases that cause lung fibrosis - scarring of lungs, loss of elasticity
  • an interstitial lung disease (ILD)
93
Q

ILD

A

Disease which causes inflammation + fibrosis of lung parenchyma

  • Idiopathic pulmonary fibrosis
  • secondary pulmonary fibrosis
  • EAA
  • cryptogenic organising pneumonia
  • asbestosis
94
Q

Pulm fibrosis patho

A
  • fibrosis may be secondary to lung damage, focal in response to irritants, or diffuse parenchymal disease

Idiopathic pulm fib (IPF)

  • progressive PF, no apparent cause

Secondary pulm fib

  • drugs - amiodarone, methotrexate, nitrofurantoin
  • conditions - A1AT, RA, SLE, SSc, sarcoidosis
95
Q

Pulm fibrosis Px

A
  • SOBOE
  • Dry cough
  • fatigue
  • IPF - bibasal find end insp crackles, finger clubbing
96
Q

Pulm fibrosis Ix

A
  • bloods - eg CRP, ANA, RF
  • spirometry - restrictive - FEV1 + FVC reduced, FEV1:FVC >70%
  • HRCT - ground-glass appearance
  • TLCO test - reduced transfer factor
  • lung biopsy
  • bronchoalveolar lavage
97
Q

Pulm fibrosis Mx

A
  • stop smoking, physio, pulm rehab, vaccines
  • home O2 if hypoxic
  • lung transplant

IPF

  • pirfenidone
  • nintedanib
98
Q

Extrinsic allergic alveolitis (EAA)

A
  • hypersensitivity pneumonitis
  • diffuse granulomatous inflammation of lung parenchyma due to inhalation of organic antigens
  • an ILD
  • T3 and T4 hypersensitivity

Bird-fancier’s lung – reaction to bird droppings

Farmer’s lung – reaction to mouldy spores in hay

Mushroom worker’s lung – reaction to specific mushroom antigens

Malt workers lung – reaction to mould on barley

99
Q

EAA Px

A

Acute (4-8hrs post-exposure)

  • SOB, dry cough, fever, rigors, chest tightness
  • crackles on ausc
  • resolves after Ag removed

Chronic (wks/months)

  • lethargy
  • SOB
  • productive cough
  • anorexia, wt loss
100
Q

EAA Ix

A
  • CXR / CT - upper/mid zone fibrosis
  • Bloods - assay for specific IgG
  • Spirometry - restrictive
  • bronchoscopy + bronchoalveolar lavage
  • biopsy
101
Q

EAA Mx

A
  • remove allergen
  • O2
  • steroids - oral prednisolone
102
Q

Pulmonary arterial hypertension (PAH)

A
  • increased pulmonary artery pressure + resistance, >20mmHg
103
Q

PAH patho

A
  • hypoxic vasoconstriction, inflammation, endothelium damage - vasoconstrictor release, increased pressure
  • right heart strain, back pressure into venous system
  • RV pumps harder -> RVH, RHF
  • thrombosis tendency
104
Q

PAH causes

A
  • Idiopathic
  • Connective tissue disease, eg SLE
  • LHF - usually due to MI / HTN
  • COPD, pulmonary fibrosis
  • PE
  • Sarcoidosis, glycogen storage disease, haem disorders
105
Q

PAH Px

A
  • SOB
  • Syncope
  • Cough
  • Tachycardia
  • Raised JVP
  • Hepatomegaly
  • Peripheral oedema
  • Hypotension
106
Q

PAH Ix

A
  • ECG - RH strain, RAD, RBBB, RVH, p pulmonale
  • CXR - RVH, dilated pulmonary arteries
  • pulm function tests
  • ECHO
  • HRCT / cardiac MRI
  • 6min walking distance
  • BNP raised
  • right heart catheterisation
107
Q

PAH Mx

A
  • diuretics, anticoagulants, LTOT if hypoxic, tx anaemia
  • tx cause
  • CCB - nifedipine, diltiazem, amlodipine - cause vasodilation
  • endothelin receptor antagonist - bosentan - prevent vasoconstriction
  • phospohdiesterase type 5 inhibitor - sildenafil - reduce pulm BP
  • prostacyclin / prostaglandin analogues - iloprost - vasodilate
  • balloon atrial septostomy
  • lung transplant
108
Q

Sarcoidosis

A
  • Chronic multisystem granulomatous disorder (nodule full of macrophages) of unknown cause
  • F, 20-39yo/60yo, black ethnic origin
  • can affect any organ - tends to be lungs/thorax
109
Q

Sarcoidosis Px

A

Acute sarcoidosis

  • fever, erythema nodosum, polyarthralgia, BHL

Pulm disease

  • dry cough, SOB, decreased exercise tolerance, chest pain

Other sx

  • lupus pernio
  • hepatomegaly, deranged LFTs, cholestasis, cirrhosis
  • lymphadenopathy, wt loss, splenomegaly, fatigue
  • salivary gland, eye, face, CNs, pituitary, renal, cardiac sx

Lofgren’s syndrome

  • erythema nodosum + BHL + polyarthralgia
110
Q

Sarcoidosis Ix

A
  • raised Ca, ACE
  • CXR, HRCT, MRI, PET
  • biopsy - non-caseating granulomas with epithelioid cells
  • other Ix for organ involvement - U/E, LFTs, ophthalmoscopy, ECG, ECHO, US liver/kidney
111
Q

Sarcoidosis Mx

A
  • mild sx - conservative
  • oral steroids - prednisolone + bisphosphonates
  • methotrexate, anti-TNF
  • lung transplant
112
Q

Lung abscess

A
  • well-circumscribed infection within lung parenchyma, contains pus
  • after aspiration pneumonia, IE, lung tumour…
  • S aureus, Klebsiella, Pseudomonas, but typically polymicrobial
113
Q

Lung abscess Px

A
  • pneumonia sx, but more subacute
  • fever, night sweats, wt loss
  • productive cough - foul sputum
  • haemoptysis
  • chest pain, SOB
  • dull to percussion, bronchial breathing
  • clubbing
114
Q

Lung abscess Ix

A
  • CXR - fluid-filled space, air-fluid level
  • sputum + blood cultures
  • sepsis workup
115
Q

Lung abscess Mx

A
  • IV abx
  • percutaneous drainage
  • surgical resection
116
Q

TB

A
  • infection caused by Mycobacterium tuberculosis
  • acid-fast bacilli - see with ZN stain - bright red cells on blue background
117
Q

TB patho

A
  • spread by saliva droplets, then several possible outcomes:

Immediate clearance

  • most cases

Primary active TB

  • Ghon focus (lung lesion) develops - granuloma forms (collection of epithelioid histiocytes) - heals by fibrosis - T4 hypersensitivity

Latent TB

  • immune system encapsulates bacteria, stops disease progression

Secondary TB

  • reactivation of latent TB to active infection
  • cavity erodes into airways

Miliary TB

  • disseminated + severe disease

Extrapulmonary TB

  • disease in other areas

Drug-resistant TB

  • resistant to tx
118
Q

TB RFs

A
  • close contact - household member
  • immigrants relatives from high prevalence areas
  • immunocompromised
  • malnutrition, homelessness, drug users, smokers, alcoholics
119
Q

BCG vaccine

A
  • intradermal, live attenuated M bovis
  • generates immune response
  • test with Mantoux test first - only give if negative
120
Q

TB Px

A

Systemic sx

  • fever, lethargy, night sweats, wt loss, lymphadenopathy

Pulm sx

  • cough, haemoptysis, chest pain, consolidation, pleural effusion

Extrapulmonary sx

  • Bone – bone pain, Pott’s
  • Abdo – ascites, lymph nodes, ileal malabsorption
  • GU – epididymitis, LUTS, pyuria
  • CNS – meningitis, sx of raised ICP
  • Cardiac – pericarditis, pericardial effusion
  • Skin – lupus vulgaris (red/brown lesions), erythema nodosum
121
Q

TB Ix

A

For immune response - previous infection, latent TB, active TB

  • mantoux test
  • IGRA

For active disease

  • CXR - patchy consolidation, hilar lymphadenopathy, pleural effusions, upper lobe cavitation, millet seed appearance
  • cultures - sputum (3x), blood, lymph node aspiration/biopsy - caseating granuloma on histology
  • NAAT
122
Q

TB Mx

A
  • MDT, notify PHE, isolate, test for other IDs

Active TB

  • Rifampicin - 6mo
  • Isoniazid (with pyridoxine vit B6) - 6mo
  • Pyrazinamide - 2mo
  • Ethambutol - 2mo

Latent TB

  • 3mo isoniazid (and vit B6) + rifampicin
  • OR 6mo isoniazid (and vit B6)

Meningeal TB

  • Tx for >12mo
  • add steroids
  • may need direct observed therapy
123
Q

Influenza

A
  • acute resp illness from infection with influenza virus
  • A/B/C serotypes, H/N Ags
  • un/complicated
  • droplet infection/contact
  • vaccinate - >65yo, pregnant, young children, healthcare workers
124
Q

Influenza Px

A
  • 1-4d incubation period
  • Fever
  • Lethargy
  • Anorexia
  • Myalgia, joint pain
  • Headache
  • Dry cough
  • Sore throat
  • Coryzal sx
125
Q

Influenza Ix

A
  • clinical dx
  • POCT / viral PCR to monitor outbreaks
126
Q

Influenza Mx

A
  • self-care
  • antivirals - tamiflu (oseltamivir), inhaled zanamivir - start <48hrs for it to be effective
127
Q

ARDS

A
  • severe inflammatory reaction in lungs
  • alveolar collapse, pulm oedema, inflammatory exudate, decreased lung compliance, fibrosis of lung tissue

Causes

  • sepsis, pneumonia, trauma, massive blood transfusion, smoke inhalation, pancreatitis

Px

  • resp distress, SOB, elevated RR
  • bl lung crackles
  • hypoxia

Ix

  • CXR - bilateral infiltrates
  • ABG - hypoxia, resp failure

Mx

  • resp support
  • prone positioning
  • ITU
  • PEEP

Phase 4 Question Knowledge (30 decks)

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