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1
Q

What is COPD?

A

Chronic obstructive pulmonary disease is a long term, progressive condition involving airway obstruction, chronic bronchitis, and emphysema

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2
Q

What is chronic bronchitis?

A

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

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3
Q

What is emphysema?

A

Damage and dilation of the alveolar sacs, decreasing the surface area for gas exchange

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4
Q

What are the causes of COPD?

A

SMOKING
Environmental causes:
- Cadmium (smelting)
- Coal
- Cotton
- Cement
- Grain

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5
Q

What are the features of COPD?

A

Cough - productive
Dyspnoea
Wheeze
Recurrent respiratory infections

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6
Q

What symptoms does COPD NOT cause?

A

Clubbing
Haemoptysis
Chest pain

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7
Q

What is the MRC dyspnoea scale?

A

Grade 1 - breathless on strenuous exercise
Grade 2 - breathless on walking uphill
Grade 3 - breathlessness that slows walking on the flat
Grade 4 - breathlessness that stops them from walking 100m on flat
Grade 5 - unable to leave house due to breathlessness

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8
Q

How is the severity of COPD graded?

A

Stage 1 - FEV1 more than 80% of predicted
Stage 2 - FEV1 50-79% of predicted
Stage 3 - FEV1 30-49% of predicted
Stage 4 - FEV1 < 30% predicted

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9
Q

How is COPD diagnosed?

A

Diagnosis based on clinical presentation and spirometry results

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10
Q

What will be seen on spirometry in a patient with COPD?

A

Obstructive picture
- FEV1:FVC ratio of less than 70%

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

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11
Q

What other investigations may be helpful in diagnosis of COPD?

A

CXR - rule out other lung pathology
FBC
Sputum culture - assess for chronic infection
ECG - heart failure and cor pulmonale
CT thorax - fibrosis, cancer or bronchiectasis

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12
Q

What is seen on CXR in COPD?

A

Hyperinflation
Bullae - air filled spaces in the lungs
Flat hemidiaphragm

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13
Q

What vaccines should patients with COPD have?

A

Pneumococcal
Annual flu vaccine
Annual covid vaccine

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14
Q

What is the initial management of COPD?

A

SABA
SAMA e.g ipratropium bromide

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14
Q

What criteria determine asthma/steroid responsive features?

A

Previous diagnosis of asthma or atopy
Raised blood eosinophil count
Variation in FEV1 of more than 400ml
Diurnal variability in peak flow of more than 20%

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15
Q

What is the second line treatment when there is asthmatic or steroid-responsive features?

A

A combination of:
- LABA
- ICS

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16
Q

What is the second line treatment where there are asthmatic/steroid responsive features present?

A

Combination of:
- LABA
- LAMA

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17
Q

What is the third line management of COPD?

A

Combination of:
- LABA
- LAMA
- ICS

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18
Q

What antibiotic is used in some patients as prophylactic therapy?

A

Azithromycin

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19
Q

What are the criteria for azithromycin antibiotic therapy?

A

Non-smoker
Optimised standard treatments
Continues exacerbations
CT thorax and sputum culture
LFTs
ECG to exclude QT prolongation

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20
Q

Which patients may receive long term oxygen therapy?

A

Severe COPD with chronic hypoxia (<92%)
Polycythaemia
Cyanosis
Cor pulmonale

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21
Q

What is cor pulmonale?

A

Right-sided heart failure due to respiratory disease

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22
Q

What are the causes of cor pulmonale?

A

COPD - most common
PE
Interstitial lung disease
CF
Primary pulmonary hypertension

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23
Q

What are the symptoms of cor pulmonale?

A

Dyspnoea
Peripheral oedema
Breathlessness on exertion
Syncope
Chest pain

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24
What are the signs of cor pulmonale on examination?
Hypoxia Cyanosis Raised JVP Peripheral oedema Parasternal heave Loud second heart sound Murmurs Hepatomegaly
25
What may be seen on a blood gas in acute COPD exacerbation?
Respiratory acidosis - Low pH - Low pO2 - Raised pCO2 - Raised bicarbonate - chronic retention
26
What other investigations are useful in an acute exacerbation of COPD?
CXR ECG FBC U&E Sputum culture Blood cultures
27
What are the target sats for a COPD patient who are at risk of retaining CO2?
88-92%
28
What are the normal target sats for a patient with COPD?
94-98%
29
What is the first line medical treatment of an acute exacerbation of COPD?
Regular inhalers and nebulisers Steroids (prednisolone 30mg OD for 7 days) Antibiotics
30
When is NIV considered in acute exacerbation of COPD?
Persistent respiratory acidosis despite maximal medical treatment
31
When are phosphodiesterase-4 inhibitors recommended for COPD?
If: - Disease is severe (FEV1 after a bronchodilator of less than 50% of predicted normal) - Patient has had 2 or more exacerbations in previous 12 months despite triple inhaled therapy
32
What is interstitial lung disease?
A group of conditions that cause inflammation and fibrosis of the lung parenchyma
33
What conditions are under interstitial lung disease?
Idiopathic pulmonary fibrosis Secondary pulmonary fibrosis Hypersensitivity pneumonitis Asbestosis
34
What is the presentation of idiopathic pulmonary fibrosis
Shortness of breath on exertion Dry cough Fatigue
35
What signs do patients with idiopathic pulmonary fibrosis have on examination?
Bibasal fine end-inspiratory crackles Finger clubbing
36
How is IPF diagnosed?
Spirometry Reduced transfer factor (TLCO) CXR - bilateral reticulonodular opacification (ground glass) CT
37
What spirometry results are seen in IPF?
Restrictive picture - FEV1 normal/decreased - FVC decreased - FEV1:FVC > 80% normal
38
What is the investigation of choice for diagnosis of IPF?
High resolution CT thorax
39
What is the management of IPF?
Pulmonary rehabilitation Smoking cessation Home oxygen (if hypoxic) Pneumococcal and flu vaccines Advanced care planning
40
Which medications can slow the progression of IPF?
Pirfenidone Nintedanib - These are used when FVC is 50-80 of predicted
41
What is a pneumothorax?
Where air gets into the pleural space, separating the lung from the chest wall
42
What is a tension pneumothorax?
A pneumothorax that causes displacement of the mediastinal structures, and compromises cardiopulmonary function This is due to a one way valve that causes air to enter the lungs, but not exit
43
What are the causes of pneumothorax?
Iatrogenic Spontaneous Trauma Lung pathologies e.g asthma, COPD, infection
44
What is the investigation of choice for a simple pneumothorax?
Erect CXR
45
What are the symptoms of pneumothorax?
Pleuritic chest pain Sudden onset shortness of breath Reduced chest expansion Reduced or absent breath sounds
46
What kinds of medical conditions can cause pneumothorax?
Connective tissue disease - Marfan's disease - Ehlers-danlos syndrome Obstructive lung disease - COPD - Asthma Infective lung disease - TB - Pneumonia Fibrotic lung disease - CF - Idiopathic pulmonary fibrosis Neoplastic disease
47
What are the signs of pneumothorax on examination?
On the affected side: Reduced or absent breath sounds Reduced chest expansion Hyper-resonant percussion Reduced vocal resonance
48
What are the additional signs of a tension pneumothorax on examination?
Deviated trachea Tachycardia Hypotension
49
When is a pneumothorax managed conservatively?
If a patient is asymptomatic (regardless of size) <2cm in size, and no high risk characteristics
50
What are the high risk characteristics of a pneumothorax?
Haemodynamic instability Significant hypoxia Bilateral pneumothorax Underlying lung disease 50 or older with significant smoking history Haemopneumothorax
51
What are the management options for pneumothorax?
Conservative management Pleural vent ambulatory device Needle aspiration or chest drain
52
What is a pleural vent ambulatory device?
A catheter that is inserted into the pleural space, which allows air to exit, but not return This can be worn as an outpatient until the pneumothorax has resolved
53
Where is a chest drain inserted?
Into the triangle of safety - formed by: - 5th intercostal space - Midaxillary line - Anterior axillary line The drain is inserted just above the rib, to avoid the neurovascular bundle that runs below the rib
54
How does a chest drain work?
One end of the drain is inserted into the chest, and the other is placed in water - this allows air to exit the chest and bubble through the water, but not re-enter the chest
55
What are the complications of a chest drain?
Air leaks around drain site Surgical emphysema (air collects in the subcutaneous tissue)
56
When will a patient require surgical management for a pneumothorax?
A chest drain fails to treat pneumothorax There is persistent air leak of the drain The pneumothorax reoccurs
57
What is the emergency management of a tension pneumothorax?
ABCDE assessment Give high flow oxygen via a non-rebreather mask Needle decompression with 14G cannula Chest drain inserted after aspiration Repeat CXR Do not delay treatment by performing investigations
58
How is needle decompression carried out in tension pnemothorax?
16 gauge cannula, inserted into the fifth intercostal space, mid-axillary line on the affected side
59
What are the risk factors for primary spontaneous pneumothorax?
Tall, slender, young Smoking Marfan syndrome Rheumatoid arthritis Family history Homocystinuria Diving or flying
60
What are the risk factors for tension pneumothorax?
Mechanical ventilation Traumatic chest injury Iatrogenic - central line, lung biopsy
61
When can patients fly post pneumothorax?
Patients can fly 1 week post-check CXR (if pneumothorax has resolved)
62
What are the complications of pneumothorax?
Re-expansion pulmonary oedema Cardiorespiratory arrest Recurrence
63
What is a pulmonary embolism?
A thrombus in the pulmonary arteries
64
What are the risk factors for PE?
Immobility Recent surgery Long haul travel Pregnancy Oestrogen therapy Malignancy Polycythaemia SLE Thrombophilia
65
What are the symptoms of PE?
Pleuritic chest pain Dyspnoea Cough Haemoptysis Fever Syncope
66
What are the clinical signs of PE?
Tachypnoea Tachycardia Hypoxia DVT Pyrexia Hypotension Elevated JVP
67
What is the PERC score?
A score that is used to rule out a PE: - Age > 50 - HR > 100 - O2 sats < 95 - Unilateral leg swelling - Haemoptysis - Recent surgery or trauma - Prior PE or DVT - Hormone use
68
What components make up the Wells score?
Clinical signs and symptoms of a DVT PE is the number 1 diagnosis or equally likely Tachycardia > 100 Immobilisation for more than 3 days or surgery in the previous four weeks Previous PE or DVT Haemoptysis Malignancy with treatment within the last 6 months
69
What are the primary investigations for PE?
CXR - exclude alternative pathology ECG - sinus tachycardia D- dimer CTPA - gold standard
70
What other conditions can cause a raised D dimer?
Pneumonia Malignancy Heart failure Surgery Pregnancy
71
What is the management of a massive PE?
Thrombolysis
72
What is the management of a non-massive PE?
Provoked - anticoagulation for 3 months Unprovoked - anticoagulation for 6 months - Anticoagulation is usually apixaban or rivaroxaban
73
What anticoagulant can be used in renal impairment?
LMWH Unfractionated heparin
74
What is the first line anticoagulant in pregnancy?
LMWH
75
How long should anticoagulation be given in cancer patients?
3-6 months and then review
76
What is the investigation of choice for PE in renal impairment?
V/Q scan (contrast used in CTPA is nephrotoxic)
77
What is hospital-acquired pneumonia?
HAP develops after more than 48 hours in hospital
78
What is the most common cause of CAP?
Streptococcus pneumoniae
79
What are the other causes of CAP?
Haemophilus influenzae Moraxella catarrhalis (immunocompromised patients) Pseudomonas aeruginosa (CF or bronchiectasis) Staphylococcus aureus (CF)
80
What are the common bacterial causes of HAP?
Psueodomonas E. coli Stapyloccocus aureus Klebsiella pneumoniae (aspiration pneumonia)
81
What are the causes of atypical pneumonia?
Legionella pneumophilia Mycoplasma pneumonia Chamydophilia pnuemoniae
82
What is the presentation of pneumonia?
Productive cough Pleuritic chest pain Dyspnoea Fever Reduced breath sounds Coarse crepitations Hypoxia Tachycardia
83
What are the initial investigations for pneumonia?
CXR FBC - raised white cells U&E ABG - respiratory failure Sputum culture CRP
84
What is CURB-65?
Confusion Urea > 7mmol/L Respiratory rate > 30 BP systolic < 90 OR diastolic < 60 > 65 years of age Community based care is score is 0 or 1 Hospital based care for patients with a score of 2 Intensive care assessment if CURB65 is 3 or more
85
What is the management of mild CAP?
Oral amoxicillin - 5 days Oral doxycycline/ clarithromycin if penicillin allergic
86
What is the management of moderate severity CAP?
Oral amoxicillin (5 days) + clarithromycin if atypical pathogen is suspected
87
What is the management of high severity CAP?
IV co-amoxiclav and clarithromycin
88
What are the complications of pneumonia?
Acute respiratory distress syndrome Sepsis Lung abscess Pleural effusion Empyema
89
What organism commonly causes bacterial pneumonia after influenza?
Staphylococcus aureus
90
What is the presentation of klebsiella pneumonia?
Red currant jelly sputum Often affects upper lobes Common after aspiration
91
How is legionella pneumonia diagnosed?
Urinary antigen test
92
What is the presentation of legionella?
Flu like symptoms including fever Dry cough Bradycardia Confusion Deranged LFTs Hyponatraemia
93
What are the features of mycoplasma pneumonia?
Prolonged and gradual onset Flu like symptoms precede pneumonia Bilateral consolidation
94
What are the complications of mycoplasma pneumonia?
Haemolytic anaemia Thrombocytopenia Erythema multiforme and nodosum GBS Pericarditis Hepatitis Pancreatitis
95
How is mycoplasma pneumonia diagnosed?
Mycoplasma serology
96
What is the management of mycoplasma pneumonia?
Doxycycline or macrolide (erythromycin/clarithromycin)
97
What bacteria is TB caused by?
Mycobacterium tuberculosis
98
What staining is used in the culture of TB?
Zeihl-Neelsen stain (turns the bacilli red against a blue background)
99
What is latent TB?
The immune system encapsulates the bacteria and stops progression of the disease
100
What is miliary TB?
Disseminated and severe disease occurs as the immune system cannot control the infection
101
What is secondary TB?
When latent TB reactivates, and in infection develops
102
What are the risk factors for TB?
Close contact with active TB Immigrants from areas with high TB prevalence Immuncompromised Homelessness IVDU Silicosis (impaires macrophage function)
103
What are the symptoms of TB?
Cough Haemoptysis Lethargy Fever Night sweats Weight loss Lymphadenopathy Erythema nodosum
104
What is Mantoux screening?
The mantoux test involves injecting tuberculin into the intradermal space on the forearm (to diagnose latent TB) - More than 5mm of induration is a positive result
105
What needs to be done to exclude an active infection in someone who is Mantoux positive?
Sputum culture to assess for active TB
106
What is seen on CXR in primary TB?
Patchy consolidation Pleural effusions Hilar lymphadenopathy
107
What is seen on CXR in reactivated TB?
Patchy or nodular consolidation with cavitation, typically in the upper zones
108
What is seen on CXR in disseminated miliary TB?
Millet seed appearance (many small 1-3mm nodules)
109
What culture samples are needed for the diagnosis of active TB?
Sputum culture (3 separate samples are collected) Mycobacterium blood cultures Lymph node aspiration or biopsy NAAT is performed on the samples
110
What is the treatment of latent TB?
Isoniazid and rifampicin for 3 months OR Isoniazid for 6 months
111
What is the treatment of active TB?
Rifampicin for 6 months Isoniazid for 6 months Pyrazinamide for 2 months Ethambutol for 2 months
112
What are the side effects of TB medications?
Rifampicin - red/orange discolouration of secretions Isoniazid - peripheral neuropathy Pyrazinamide - hyperuricaemia Ethambutol - colourblindness and reduced visual acuity
113
What can be prescribed alongside isoniazid to prevent peripheral neuropathy?
Pyridoxine (vitamin B6)
114
What is the pathophysiology of asthma?
Airway hyperresponsiveness is triggered by environmental factors - Activation of Th2 cells results in eosinophil Activation, IgE production and mast cell degranulation - This causes a reversible airflow obstruction
115
What are the risk factors for asthma?
History of atopy Family history Exposure to allergens Occupational exposure
116
What are the typical triggers for asthma?
Infection Nighttime or early morning Exercise Animals Cold, damp or dusty air Strong emotions
117
What are the clinical features of asthma?
Episodic shortness of breath - diurnal variation Dry cough Wheeze Chest tightness
118
What are the primary investigations for asthma?
Fractional exhaled nitric oxide (FeNO) Spirometry and bronchodilator reversibility Peak flow diary
119
What FeNO level is indicative of asthma?
>50ppb
120
What peak flow variability is indicative of asthma?
>20%
121
What spirometry results are indicative of asthma?
An FEV1:FVC ratio of less than 70%
122
What are the presenting features of an acute asthma exacerbation?
Progressive shortness of breath Use of accessory muscles Tachypnoea Symmetrical expiratory wheeze
123
What are the features of a moderate asthma exacerbation?
Peak flow 50-75% of best
124
What are the features of a severe asthma exacerbation?
Peak flow 33-50% of best/predicted RR > 25 HR > 110 Unable to complete sentences
125
What are the features of a life-threatening asthma exacerbation?
PEFR < 33% SpO2 < 92% PO2 < 8 PCO2 normal Altered consciousness Exhaustion Arrhythmia Hypotension Silent chest
126
What are the features of a near-fatal asthma attack?
High pCO2
127
What investigations are helpful in an acute asthma exacerbation?
PEFR ABG Inflammatory markers - look for infective trigger CXR - hyperexpansion/infection
128
What is the initial management of an acute asthma exacerbation?
Admission - all patients with life-threatening asthma Oxygen Bronchodilation - SABA 40-50mg oral prednisolone Ipratropium bromide nebulisers if not responding or if life-threatening asthma
129
What is the further management of an acute asthma exacerbation?
IV magnesium sulfate IV aminophylline ICU admission
130
What is the criteria for discharge in acute asthma exacerbation?
Have been stable on their discharge medication for 12-24 hours Inhaler technique checked and recorded PEF > 75% of best or predicted
131
What is the first line management of asthma?
Low dose ICS/formoterol combination inhaler (AIR therapy)
132
What is the second line management of asthma?
Low dose MART (combined ICS/formoterol taken daily and as required)
133
What is the third line management of asthma?
Moderate dose MART
134
What is the fourth line management of asthma?
Check the FeNO level and eosinophil count - If either of these is raised, refer to specialist - Consider trial of leukotriene receptor antagonist or LAMA
135
What is sarcoidosis?
A chronic granulomatous disorder characterised by non-caseating granulomas
136
What is the epidemiology of sarcoidosis?
More common in: - Aged 20-39 or around 60 - Women - Black ethnic origin
137
What are the skin features of sarcoidosis?
Erythema nodosum Lupus pernio - raised purple lesions often on the cheek and nose
138
What are the lung features of sarcoidosis?
Non-productive cough Dyspnoea Cervical and submandibular lymphadenopathy Pulmonary fibrosis Pulmonary nodules
139
What are the possible systemic symptoms of sarcoidosis?
Fever Fatigue Weight loss
140
What are the potential liver features of sarcoidosis?
Liver nodules Cirrhosis Cholestasis
141
What are the eye features of sarcoidosis?
Uveitis Conjunctivitis Optic neuritis
142
What are the MSK manifestations of sarcoidosis?
Arthralgia Arthritis Myopathy
143
What is Lofgren's syndrome?
A specific presentation of sarcoidosis with a classic triad of symptoms: - Erythema nodosum - Bilateral hilar lymphadenopathy - Polyarthralgia
144
What are the differentials of sarcoidosis?
TB Lymphoma Hypersensitivity pneumonitis HIV Toxoplasmosis Histoplasmosis
145
What investigations are used in the diagnosis of sarcoidosis?
Blood tests: - ACE - raised - Serum calcium - raised Imaging: - CXR - hilar lymphadenopathy - CT chest - hilar lymphadenopathy and pulmonary nodules
146
What other investigations may be considered in sarcoidosis?
Spirometry - restrictive lung disease Lung tissue biopsy ECG - sarcoidosis can cause heart block LFTs for liver involvement U&Es for kidney involvement
147
What is the staging of sarcoidosis on CXR?
Stage 0 - normal Stage 1 - bilateral hilar lymphadenopathy Stage 2 - bilateral hilar lymphadenopathy and interstitial infiltrates Stage 3 - diffuse pulmonary infiltrates without hilar lymphadenopathy Stage 3 - diffuse fibrosis
148
What are the indications for steroids in sarcoidosis?
Symptomatic and stage 2 or 3 on CXR Extrapulmonary involvement Hypercalcaemia
149
What is the treatment of symptomatic sarcoidosis or progressive disease?
First line - corticosteroids Second line - immunosuppressants (methotrexate) End stage - consider lung transplantation
150
What is the management of asymptomatic or non-progressive disease?
Conservative management
151
What are the complications of sarcoidosis?
Pulmonary hypertension Respiratory failure Cor pulmonale Heart block Cranial nerve palsies Meningeal disease Uveitis
152
What is bronchiectasis?
Permenant dilation of the bronchi
153
What are the causes of bronchiectasis?
Idiopathic - most common Pneumonia Whooping cough TB Alpha-1-antitrypsin deficiency Connective tissue disorders Cystic fibrosis
154
What are the risk factors for bronchiectasis?
Increasing age Smoking Female sex
155
What is yellow nail syndrome?
A triad of yellow nails, bronchiectasis and lymphoedema
156
What is the clinical presentation of bronchiectasis?
Shortness of breath Excess sputum production Haemoptysis Weight loss Recurrent chest infection Chronic productive cough
157
What are the signs of bronchiectasis on examination?
Weight loss Finger clubbing Raised JVP Peripheral oedema Coarse crackles during inspiration Scattered wheezes and squeaks
158
What is the definitive investigation for diagnosis of bronchiectasis?
High resolution CT chest - Bronchial dilation and bronchial wall thickening
159
What other investigations are used in the diagnosis of bronchiectasis?
CXR - diated airways with thickened walls Sputum cultures - identifying colonising pathogens FBC - assess for infection
160
What are the most common infective organisms in bronchiectasis?
Haemophilus influenza Pseudomonas aeruginosa
161
What is the management of bronchiectasis?
First line - Chest physiotherapy - Annual influenza vaccine - Antibiotics for acute exacerbations Second line - Mucoactive agent - carbocisteine - Bronchodilator - Long term antibiotics - macrolide for three or more exacerbations a year
162
What are the complications of bronchiectasis?
Infective exacerbations Bacterial colonisation Pneumothorax Respiratory failure Cor pulmonale
163
What is the management of an infective exacerbation?
Sputum culture (before antibiotics) Extended course of antibiotics - 7-14 days - Ciprofloxacin for pseudomonas
164
What is acute bronchitis?
A chest infection (that is usually self limiting) caused by inflammation of the trachea and major bronchi
165
What is the presentation of acute bronchitis?
Cough - may or may not be productive Sore throat Rhinorrhoea Wheeze Low grade fever
166
How is acute bronchitis differentiated from pneumonia?
Sputum, wheeze and breathlessness are more common in pneumonia No focal chest signs in acute bronchitis other than wheeze Systemic symptoms are more common in pneumonia
167
What is the first line management of acute bronchitis?
Analgesia Good fluid intake
168
When are antibiotics considered for acute bronchitis?
If patients are: - Systemically very unwell - Have pre-existing co-morbidities - Have a CRP of 20-100
169
What is the first line antibiotic for acute bronchitis?
Doxycycline - Amoxicillin in children and pregnant women
170
What is a pleural effusion?
A pleural effusion is a collection of fluid in the pleural space
171
What is the difference between exudative and transudative pleural effusion?
Exudative effusion has a higher protein content (>30g/L), whereas transudative effusion has a lower protein content (<30g/L)
172
What are the causes of transudative effusion?
Heart failure Cirrhosis Hypothyroidism Meigs syndrome
173
What are the causes of exudative effusion?
Malignancy Pneumonia Rheumatoid arthritis TB
174
What is Meigs syndrome?
A triad of a benign ovarian tumour, pleural effusion and ascites
175
What is the presentation of pleural effusion?
Shortness of breath Cough Pleuritic chest pain
176
What examination findings may be seen in pleural effusion?
Reduced chest expansion and breath sounds on affected side Decreased tactile or vocal fremitus Dullness to percussion Pleural friction rub Tracheal deviation in very large effusions
177
What is the initial investigation for pleural effusion?
CXR
178
What is seen on CXR in pleural effusion?
Blunting of costophrenic angle Fluid in the lung fissures Large effusions will have a meniscus Tracheal and mediastinal deviation
179
What tests can be performed under pleural fluid analysis?
pH Protein LDH Culture and staining Cytology
180
What is Light's criteria?
If protein levels is 25-35 g/, Light's criteria should be applied: An exudate is more likely if: - Pleural fluid protein divided by serum protein is > 0.5 - Pleural fluid LDH divided by serum LDH is > 0.6 - Pleural fluid LDH is more than 2/3 of the upper limit of normal serum LDH
181
What is the management of pleural effusion?
Treat underlying cause Thoracentesis Chest tube drainage
182
What is empyema?
Empyema is an infected pleural effusion
183
When should empyema be suspected?
In a patient with an improving pneumonia, but a new or ongoing fever
184
How is pulmonary hypertension defined?
Mean pulmonary arterial pressure of more than 20mmHg at rest
185
How does pulmonary hypertension cause right heart strain?
Increased resistance in the pulmonary vasculature leads to increased pressure in the right ventricle Increased pressure results in increased ventricular filling and stroke volume, which further increases pulmonary arterial pressure Over time right ventricular hypertrophy develops
186
What are the groups of pulmonary hypertension?
Group 1 - idiopathic pulmonary hypertension Group 2 - pulmonary hypertension due to left heart failure Group 3 - due to chronic lung disease Group 4 - due to pulmonary vascular disease Group 5- miscellaneous causes
187
What conditions can cause group 2 pulmonary hypertension?
Heart failure Valvular heart disease HOCM
188
What conditions can cause group 3 pulmonary hypertension?
COPD Interstitial lung disease OSA Chronic high altitude
189
What conditions can cause group 4 pulmonary hypertension?
PE Pulmonary artery obstruction
190
What conditions can cause group 5 pulmonary hypertension?
Haematological disorders Metabolic disorders Sarcoidosis
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What is the clinical presentation of pulmonary hypertension?
Shortness of breath Syncope Tachycardia Raised JVP Hepatomegaly Peripheral oedema
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What signs of pulmonary hypertension may be seen on examination?
Raised JVP Right parasternal heave Loud second heart sound Pulmonary or tricuspid regurgitation
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What investigations are initially performed in pulmonary hypertension?
ECG CXR BNP Echocardiogram
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What is the gold standard investigation for pulmonary hypertension?
Right heart catheterisation to directly measure pulmonary pressure
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What ECG changes can occur in pulmonary hypertension?
P pulmonale (peaked P waves) Right ventricular hypertrophy - tall R waves in V1 and V2, deep S waves in V5 and V6 Right axis deviation RBBB
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What changes may be seen on CXR in pulmonary hypertension?
Dilated pulmonary arteries Right ventricular hypertrophy
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What is the first line management of idiopathic pulmonary hypertension?
Calcium channel blockers - nifedipine and diltiazem Pulmonary vasodilators - Prostacyclin - Phosphodiesterase type 5 inhibitors (sildenafil) - Endothelin receptor antagonists
198
What are the complications of pulmonary hypertension?
Right heart failure Pericardial effusion and tamponade Hepatic congestion
199
What is the biggest cause of lung cancer?
Smoking
200
What are the histological types of lung cancer?
Small cell lung cancer Non-small cell lung cancer
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How can non-small cell lung cancer be further divided?
Adenocarcinoma Squamous cell carcinoma Large-cell carcinoma
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How does small cell lung cancer cause paraneoplastic syndromes?
Small cell lung cancer contains neurosecretory granules that release neuroendocrine hormones
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What is the clinical presentation of lung cancer?
Shortness of breath Cough Haemoptysis Finger clubbing Recurrent pneumonia Weight loss Lymphadenopathy (supraclavicular)
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What are the risk factors for lung cancer?
Tobacco smoking Passive smoke exposure Occupational exposure Radon exposure Family history of lung cancer Radiation to the chest Air pollution Immunosuppression Increasing age
205
What nerve palsies can lung cancer cause?
Recurrent laryngeal nerve palsy - If tumour presses on recurrent laryngeal nerve while passing through the mediastinum - Causes hoarse voice Phrenic nerve palsy - Causes diaphragm weakness and presents with shortness of breath
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What are the extrapulmonary manifestations of lung cancer?
Superior vena cava obstruction - direct compression of the tumour on the superior vena cava Horner's syndrome - caused by pancoast tumour SIADH - ectopic ADH secreted by a small cell lung cancer Cushing's syndrome - ectopic ACTH secretion by small cell lung cancer Hypercalcaemia - ectopic parathyroid hormone Limbic encephalitis - paraneoplastic syndrome where small cell lung cancer causes the immune system to make antibodies to tissues in the brain Lambert-Eaton myasthenic syndrome
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What is the two week wait referral criteria for patients with suspected lung cancer?
Patients over 40 with the following should be offered a CXR within two weeks: - Clubbing - Lymphadenopathy - Recurrent or persistent chest infections - Raised platelet count - Chest signs of lung cancer
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When else should a CXR be considered?
Patients over 40 with: - Two or more unexplained symptoms and have never smoked - One or more unexplained symptoms in patients that have previously smoked
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What is the first line investigation in suspected lung cancer?
CXR
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What are the findings on CXR suggestive of lung cancer?
Hilar enlargement Peripheral opacity Pleural effusion Collapse
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What further imaging is used in the diagnosis of lung cancer?
Staging CT scan - CT-TAP PET-CT Bronchoscopy with endobronchial ultrasound Histological diagnosis - biopsy of tumour cells
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What is the management of lung cancer?
Holistic support and MDT approach Smoking cessation Advanced care planning where appropriate First line medical - chemotherapy Immunotherapy for advanced non-small cell lung cancer Radiotherapy Surgical management - lobectomy, wedge resection, pneumonectomy
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What is an URTI?
An upper respiratory tract infection, usually viral in aetiology
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What are the common causative pathogens of URTI?
Rhinoviruses Coronaviruses Adenoviruses
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What is the clinical presentation of URTI?
Coryza Sneezing Cough Sore throat Low-grade fever Malaise Headache Hoarse voice
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What are the differentials of URTI?
Allergic rhinitis Influenza Whooping cough Infectious mononucleosis Nasal foreign body
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What is the management of URTI?
Adequate fluid intake Rest Vapor rubs Inhaling steam for nasal congestion Lozenges Simple analgesia Intranasal congestants - only to be used for a short period of time
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What are the complications of URTI?
Acute otitis media Sinusitis Exacerbations of COPD or asthma Pneumonia
219
What is Goodpasture's syndrome?
An autoimmune disease where antibodies attack a type IV collagen found in the basement membrane of the lungs and the kidneys
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What is the pathophysiology of Goodpasture's syndrome?
The anti-glomerular basement membrane antibodies lead to small vessel vasculitis, which causes bleeding in the lungs, and renal failure
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What is the presentation of Goodpasture's syndrome?
Haemoptysis Cough Shortness of breath Nausea and vomiting Chest pain Decreased urine output Fatigue and malaise Haematuria
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What is the definitive investigation for diagnosis of Goodpasture's syndrome?
Renal biopsy
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What other investigations are useful in the diagnosis of Goodpasture's syndrome?
Anti-GBM antibody titre ANCA antibodies U&Es Urinalysis Chest imaging
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What is seen on CXR and CT in Goodpasture's syndrome?
XR - diffuse opacities CT - ground glass opacities
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What are the differentials of Goodpasture's syndrome?
SLE Granulomatosis with polyangiitis Anti-GBM disease
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What are the differences between Goodpasture's syndrome and Anti-GBM disease?
No lung involvement in anti-GBM disease
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What is the acute management of Goodpasture's syndrome?
Plasmapheresis Prednisolone - tapered over 3 months Cyclophosphamide
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What is the long term management of Goodpasture's syndrome?
Maintenance therapy - Azathioprine for immune suppression - Low dose prednisolone Smoking cessation
229
What are the complications of Goodpasture's syndrome?
Pulmonary haemorrhage Plasmapheresis related bleeding Cyclophosphamide related neutropenia Immunosuppression related infected CKD Long term steroid complications
230
What is granulomatosis with polyangiitis?
An ANCA associated systemic vasculitis affecting small and medium sized vessels
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What is the pathophsiology of granulomatosis with polyangiitis?
ANCA is produced by B cell activation
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What are the four types of influenza?
Influenza A - capable of causing pandemics and epidemics Influenza B - capable of epidemics Influenza C Influenza D - only found in cattle
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What are the risk factors for severe influenza infection?
Hyposplenism Chronic disease Diabetes mellitus Immunosuppression Obesity Pregnancy
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What is the incubation period of influenza?
1-4 days
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How long do patients with influenza remain infectious?
7-21 days
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What is the presentation of influenza?
Fever > 37.8 Nonproductive cough Myalgia Headache Malaise Sore throat Rhinitis
237
What are the differentials of influenza?
Sepsis Meningitis Common cold LRTI Infectious mononucleosis
238
What investigation can be used to diagnose influenza?
Viral PCR - should not delay treatment
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What antiviral treatment can be used for influenza?
Oseltamivir Zanamivir
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When can antivirals be used for treatment of influenza?
Within 48 hours of symptom onset Patient is at risk of complications
241
What are the complications of influenza?
Viral pneumonia Secondary bacterial pneumonia (s. aureus) Myocarditis Heart failure Encephalopathy
242
What is hypersensitivity pneumonitis?
Hypersensitivity induced lung damage due to a variety of inhaled organic particles
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What type of hypersensitivity reaction is involved in hypersensitivity pneumonitis?
Type III and type IV
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What are examples of types of hypersensitivity pneumonitis?
Bird fanciers lung Farmers lung Malt workers lung Mushroom workers lung
245
What is the acute presentation of hypersensitivity pneumonitis?
Dyspnoea Dry cough Fever
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What is the chronic presentation of hypersensitivity pneumonitis?
Lethargy Dyspnoea Productive cough Anorexia and weight loss
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What investigations are involved in the diagnosis of hypersensitivity pneumonitis?
CXR Bronchoalveolar lavage Serological assays for IgG antibodies
248
What is seen on CXR in hypersensitivity pneumonitis?
Upper and mid zone fibrosis
249
What is the management of hypersensitivity pneumonitis?
Avoid precipitating factors Oral glucocorticoids

Finals 🩺 (28 decks)

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