Respiratory Flashcards
What are the British thoracic society guidelines on what constitutes an acute severe asthma attack?
PEF 33-50% best or predicted
Resp rate 25 or above
Heart rate 110 or above
Inability to complete sentences in 1 breath
What are the British thoracic society guidelines on what constitutes a moderate asthma attack?
Increasing symptoms
PEF >50-75% best or predicted
No features of acute severe asthma
What are the British thoracic society guidelines on what constitutes a life threatening asthma attack?
PEF <33% best or predicted SpO2 less than 92% PaO2 less than 8kPa Normal PaCO2 (4.6-6 kPa) Silent chest Cyanosis Poor resp effort Arrhythmia Exhaustion, altered conscious level Hypotension
What are the British thoracic society guidelines on what constitutes a near fatal asthma attack?
Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures
For someone presenting with an acute severe asthma attack, what drugs should be administered immediately and by what route? If they fail to respond to this, what should you give now?
Oxygen Nebulised salbutamol or terbutaline Nebulised ipratromium bromide Oral prednisolone or IV hydrocortisone If fails: IV magnesium sulphate, IV salbutamol, IV aminophylline
Why is a normal CO2 result in a patient with an acute severe asthma attack worrying? What further intervention would you do for this patient?
Suggests patient is tiring, would expect it to be low if they were adequately compensating
Intubation/ventilation in ITU
A 23 year old man is seen in ED with 10% pneumothorax of the right lung. His BP and pulse are stable. What needs to be done?
Oxygen therapy only as he is stable
What are risk factors for DVT and PE?
Thrombophilia - protein s and c Factor VIII excess Factor V Leiden Pregnancy Pre eclampsia Surgery Age over 35 Malignancy Smoking Obesity Immobility Parity above 4
What is bilateral hilar lymphadenopathy characteristic of?
Sarcoidosis
What skin condition is acute sarcoidosis associated with?
Erythema nodosum
What is amyloidosis?
Extra cellular deposits of degradation resistant protein amyloid
What are causes of amyloidosis?
Primary: no cause is found
Secondary: TB, bronchiectasis, RA, osteomyelitis, neoplasia
How is a diagnosis of amyloidosis made?
Rectum biopsy
Congo red staining of affected tissue
Give examples of transudative causes of pleural effusion
Nephrotic syndrome
Liver cirrhosis
Heart failure
What are features of COPD on a chest X-ray?
Hyperinflation
Flattened hemidiaphragms
Hyperlucent lung fields
If there is a white out on chest X-ray and the trachea is pulled towards it, what are differentials?
Pneumonectomy
Complete lung collapse
Pulmonary hypoplasia
If there is a complete white out on chest X-ray and the trachea is central, what are differentials?
Consolidation
Pulmonary oedema
Mesothelioma
If there is a complete white out on chest X-ray but the trachea is pushed away, what are differentials?
Pleural effusion
Diaphragmatic hernia
Large thoracic mass
What common clinical signs are found with a PE?
Tachypnoea
Crackles
Tachycardia
Fever
What is the Wells score for PE?
Clinical signs and symptoms of DVT - leg swelling and pain on palpation (3) Alternative diagnosis less likely (3) Heart rate >100 (1.5) Immobilisation for more than 3 days or surgery in previous 4 weeks (1.5) Previous DVT/PE (1.5) Haemoptysis (1) Malignancy (1) Score more than 4: PE likely
What are features of small cell lung cancer?
Central
Associated ectopic ADH, ACTH secretion: Hyponatraemia, Cushings
Lambert Eaton syndrome
What is management of small cell lung cancer?
Usually metastatic at diagnosis
Early stage disease: T1-2a surgery
Limited disease: chemotherapy and adjuvant radiotherapy
Extensive disease: palliative chemo
What are the BTS guidelines for management of spontaneous pneumothorax?
Primary: if rim of air is <2cm and patient not short of breath, discharge, otherwise attempt aspiration, if this fails then chest drain, advice stop smoking
Secondary: if over 50 and rim of air over 2cm or SOB then chest drain, rim of 1-2cm - aspiration, if this fails then chest drain. All patients admitted for 24h. If less than 1cm rim give oxygen and admit for 24h
What are the steps of asthma management in the new BTS guidelines?
Initial step: low dose inhaled corticosteroid in combination with a short acting beta agonist
Next step: add long acting beta agonist ideally in combo inhaler
Next step: if no response to LABA, stop and increase ICS to medium. If response to LABA, continue and increase ICS to medium. Alternative try a leukotriene antagonist, SR theophylline or LAMA
Next step: trials of ICS high dose, add fourth drug, refer to specialist care
Next step: regular oral steroids at lowest dose to achieve control
What are features of mycoplasma pneumonia?
Prolonged and gradual onset
Flu like symptoms precede dry cough
Bilateral consolidation on X-ray
What are some complications of mycoplasma pneumonia?
Cold agglutins (IgM) may cause haemolytic anaemia Erythema multiforme/nodosum Meningoencephalitis Guillain-Barré syndrome Bullous myringitis: vesicles on TM Pericarditis/myocarditis Hepatitis Pancreatitis Acute glomerulonephritis
What investigations are done for mycoplasma pneumonia?
Mycoplasma serology
Positive cold agglutination test
What is the management of mycoplasma pneumonia?
Erythromycin/clarithromycin
What is given to treat low or moderate severity community acquired pneumonia?
Oral amoxicillin. Add macrolide if admitted
What should be given to treat high severity community acquired pneumonia?
IV co amoxiclav and clarithromycin
or cefuroxime and clarithromycin
or cefotaxime and clarithromycin
What are some intrathoracic complications of carcinoma of the bronchus?
Pleural effusions
Recurrent laryngeal nerve palsy
SVC obstruction
Horners syndrome
What are clinical features of mesothelioma?
Chest pain
Dyspnoea
Blood stained pleural effusion
What causes farmers lung?
Hypersensitivity reaction to saccharopolyspora rectivirgula
What is the treatment of choice for farmers lung (hypersensitivity pneumonitis)?
Prednisolone
What are clinical features of cystic fibrosis?
Persistent productive cough (esp winter)
Haemoptysis
Clubbing
Low pitched inspiratory and expiratory crackles
What does chest X-ray of a patient with cystic fibrosis show?
Cystic shadows
Fluid levels
Tramline or ring shadows
What is the acute management of asthma?
Oxygen Salbutamol nebs Steroids IV CXR rule out pneumothorax Magnesium 2g over 30 mins IV theophylline ITU review if silent chest or tiring patient
How does idiopathic pulmonary fibrosis typically present?
Male aged 50-70
Progressive exertional dyspnoea
Clubbing
Restrictive picture on spirometry
Which virus causes bronchiolitis?
Respiratory syncytial virus
Which virus causes croup?
Parainfluenza virus
Which virus causes the common cold?
Rhinovirus
Which bug is the most common cause of community acquired pneumonia?
Streptococcus pneumoniae
Which bug is the most common cause of bronchiectasis exacerbations?
Haemophilus influenzae
Which bug causes pneumonia particularly following influenza?
Staphylococcus aureus
What is the common cause of pneumonia in HIV patients?
Pneumocystis jiroveci
What are general management pieces of advice to give to a patient with COPD?
Smoking cessation advice
Annual influenza vaccination
One off pneumococcal vaccination
What is first line treatment for COPD?
SABA or SAMA
What is the second step in COPD management?
If FEV1 >50%: LABA or LAMA
If FEV1 <50%: LABA and ICS in combo inhaler or LAMA
What are features of cor pulmonale?
Peripheral oedema
Raised JVP
Systolic parasternal heave
Loud P2
How do you treat cor pulmonale?
Loop diuretic for oedema
Long term oxygen therapy
What factors may improve survival in patients with stable COPD?
Smoking cessation
Long term oxygen therapy in those who fit criteria
Lung volume reduction surgery in selected patients
What are key indications for non invasive ventilation?
COPD with respiratory acidosis pH 7.25-7.35
Type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
Cardiogenic pulmonary oedema unresponsive to CPAP
Weaning from tracheal intubation
What are some causes of bronchiectasis?
Post infective: TB, measles, pertussis, pneumonia
Cystic fibrosis
Bronchial obstruction: cancer, foreign body
Immune deficiency: selective IgA, hypogammaglobulinaemia
Allergic bronchopulmonary aspergillosis
Ciliary dyskinetic syndrome: kartageners, youngs
Yellow nail syndrome
What is a ghon focus?
Lesion seen in lung caused by TB
Calcified tuberculous caseating granuloma
What is miliary TB?
Erosion through a vein that leads to widespread dissemination of mycobacterium tuberculosis to a range of different organs including bones and kidneys
In what range of pH is NIV considered of most benefit in patients with COPD?
7.25-7.35
How is PCP pneumonia best detected?
Bronchoscopy and bronchial aspirate
What is Potts disease?
Tuberculosis infection of the spine
What is the clinical picture of aspergillus fumigatus?
Wheeze Cough Dyspnoea Recurrent pneumonia Raised serum IgE Raised ESR Raised eosinophil count
What are contraindications to surgery for lung cancer?
SVC obstruction FEV <1.5L Malignant pleural effusion Vocal cord paralysis Stage IIIb or IV Tumour near hilum
What are characteristics of squamous cell cancer of the lung?
Central
PTHrP secretion - hypercalcaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy
What are features of adenocarcinoma of the lung?
Peripheral
Most common lung cancer in non smokers
What are features of large cell lung carcinoma?
Peripheral
Anaplastic, poorly differentiated tumours with poor prognosis
May secrete beta HCG
What is Kartageners syndrome?
Primary ciliary dyskinesia Dextrocardia or situs inversus Bronchiectasis Recurrent sinusitis Subfertility
What are features of a mycoplasma pneumoniae pneumonia?
Prolonged gradual onset
Flu like symptoms precede a dry cough
Bilateral consolidation
What are possible complications of mycoplasma pneumoniae?
Cold agglutinins (IgM) - haemolytic anaemia, thrombocytopenia Erythema multiforme, erythema nodosum Meningoencephalitis Guillain Barre Bullous myringitis Pericarditis/myocarditis Hepatitis Pancreatitis Acute glomerulonephritis
How is mycoplasma pneumoniae investigated?
Mycoplasma serology
Positive cold agglutination test
How is mycoplasma pneumoniae managed?
Erythromycin /clarithromycin
Which patients should be assessed for long term oxygen therapy?
Severe airflow obstruction: FEV1 <30% predicted Cyanosis Polycythemia Peripheral oedema Raised JVP Oxygen sats less than 92% on air
How is assessment for long term oxygen therapy made in patients with COPD?
Measuring ABG on 2 occasions at least 3 weeks apart
Who should be offered long term oxygen therapy?
PO2 <7.3 or if 7.3-8 and: Secondary polycythemia Nocturnal hypoxaemia Peripheral oedema Pulmonary HTN
What is the most appropriate next step for a 71 year old patient presenting with a 2 month history of cough and associated weight loss who has a suspicious lung mass on chest X-ray?
Contrast enhanced CT of chest, liver and adrenals
In which respiratory condition would a patient present with desaturation on exertion but with a normal chest X-ray and a history of recurrent chest infections?
Pneumocystis jiroveci
What is the most common opportunistic infection in AIDS? Who should have prophylaxis?
Pneumocystis jiroveci
All patients with CD4 count below 200
How is pneumocystis jeroveci managed?
Co trimoxazole
IV pentamidine in severe cases
Steroids if hypoxic
What are features of idiopathic pulmonary fibrosis?
Progressive exertional dyspnoea
Bibasal crackles on auscultation
Dry cough
Clubbing
What investigation is required to make a diagnosis of idiopathic pulmonary fibrosis?
High resolution CT
What is the management for idiopathic pulmonary fibrosis?
Pulmonary rehabilitation
Pirfenidone (anti fibrotic agent)
Supplementary oxygen
Lung transplant
What is the prognosis for idiopathic pulmonary fibrosis?
3-4 years life expectancy
What is the main therapeutic benefit of using inhaled corticosteroids in COPD?
Reduced frequency of exacerbations
What is the target INR for a patient with recurrent PEs?
3.5
68 year old gentleman presents to GP with dry, persistent cough for anumber of weeks. Wife has noticed is becoming more short of breath when exercising. Reduced exercise since retirement so not noticed any change himself. Current smoker of 10/day for 30 years. Retired labourer/builder
O/E: slight SOB on entering the consultation room, Evidence of digital clubbing. Bilateral inspiratory crackles on auscultation. What are differential diagnoses?
Heart failure COPD PE Lung Cancer Infection Interstitial lung disease
What specific questions might you want to ask in a patient who you suspect has interstitial lung disease?
Environmental / occupational exposure: Asbestos, industrial dust, farmer, Pigeon breeding, Contaminated ventilation
PMH of connective tissue disease
Detailed drug history: Abx – nitrofurantoin, Anti-inflammatories – methotrexate, Biological agents, CV agents – amiodarone, Chemotherapeutics
What are some physiological and radiological features of interstitial lung disease?
Physiological: Restrictive ventilation defect on lung function tests, Small lung volumes, Reduced gas transfer
Radiological: CXR – small lung volumes with reticulonodular shadowing, HRCT – ground glass changes, honeycomb cysts and traction bronchiectasis
What investigations might you want to do for interstitial lung disease?
Bloods:FBC – lymphopenia in sarcoidosis, eosinophilia, neutrophilia inhypersensitivity pneumonitis, ESR, CRP – non specifically elevated, Ca2+ - raised in sarcoidosis
Auto-immune screen – connective tissue disease
Imaging: CXR, HRCT
Special test: Lung function tests – restrictive pattern, Bronchoscopy, Bronchoalveolar lavage – may differentiate diagnosis / exclude infection, Biopsy – useful in sarcoidosis, Surgical biopsy
What is idiopathic pulmonary fibrosis?
Progressive fibrosing interstitial pneumonia of unknown origin
Clinical syndrome associated with histological and radiological pattern of Usual Interstitial Pneumonia
Patchy interstitial fibrosis
Architectural alteration – honeycomb changes
Repeated episodes of focal damage to the alveolar epithelium
Diagnosis of exclusion based on history, examination, investigations
How is idiopathic pulmonary fibrosis diagnosis?
HRCT with characteristic features has a high positive predictive value
If diagnostic uncertainty = biopsy
Ideally surgical lung biopsy, Transbronchial lung biopsy invariably insufficient at obtaining tissue sample
How is idiopathic pulmonary fibrosis managed?
Pirfenidone – recommended by NICE but only with FVC 50-80% predicted (downregulation of production of growth factors and procollagens)
Supportive measures: Exercise, Physio, Vaccinations, Oxygen in hypoxaemia
Lung transplant
What is sarcoidosis?
Multisystem granulomatous disorder characterised by presence of non-caseating granulomas
Granulomas consist of focal accumulations of epithelioid cells, macrophages and lymphocytes (mainly T cells)
Commonly affects young adults
Presents with bilateral hilar lymphadenopathy, pulmonary infiltration
and skin/eye lesions
Unknown aetiology
What are some extra pulmonary manifestations of sarcoidosis?
Skin lesions: Erythema nodosum
Occular: Anterior uveitis – misting of vision, pain and red eye
Metabolic manifestations: Hypercalcaemia
CNS
Bone and joint involvement: Bone cysts
Hepatosplenomegaly
What is the management for sarcoidosis?
Mainstay = corticosteroids if symptomatic
Spontaneous remission occurs in the majority of patients therefore if no organ damage treatment can be held for 6 months
If impairment appears – prednisolone to be started immediately
What is the prognosis for sarcoidosis?
More severe in certain groups - Afro-Caribbean ethnicity
Fatal in fewer than 5% in the UK
Remission within 2 years in 2/3rds of pt with bihilar lymphadenopathy alone
Lung function tests useful to monitor progression
What is extrinsic allergic alveolitis?
Widespread diffuse inflammatory reaction of small airways and
alveoli due to inhalation of different antigens
Commonly microbial spores of contaminated vegetable matter
Farmer’s lung – mouldy hay
Bird fancier’s lung – handling pigeons, proteins present in the feathers and excreta
Inhalation of antigen leads to allergic response through deposition of immune complexes and development of small non-caseating
granulomas
What are features of extrinsic allergic alveolitis?
Fever, malaise, cough and SOB
Develop several hours after exposure to antigen
O/E: Coarse end-inspiratory crackles and wheeze throughout chest
Ventilation-perfusion mismatch causing cyanosis
If continued exposure – chronic illness with severe weight loss andfeatures of idiopathic pulmonary fibrosis
What is the management for extrinsic allergic alveolitis?
Prevention: avoidance of trigger
Induce regression with prednisolone
What are some examples of occupational lung disease?
Coal worker’s pneumoconiosis
Asbestosis
Mesothelioma
What can coal workers pneumoconiosis develop into?
Simple pneumoconiosis – deposition of coal dust
Progressive massive fibrosis - round fibrotic masses with necrotic central cavities. Mixed restrictive and obstructive ventilation defect
Why does asbestos cause significant problems with lungs?
Highly resistant fibres that readily get trapped in the lung – resistant to macrophage and neutrophil enzymatic destruction
How might mesothelioma present?
Persistent chest wall pain
Pleural effusions
58 year old man. Presenting with increasing SOB and cough productive of purulent green sputum – increased over the past 3 days. Regular medications including Spiriva 18 micrograms OD, Ventolin MDI 200micrograms PRN, Indapamide 2.5mg OD, Atorvastatin 10mg OD. No known drug allergies. PMH – COPD diagnosed 5 years ago. Current smoker 60 pack year history. On examination: Speaking in partial sentences, RR 29, SpO2 85% on air, widespread expiratory wheeze and inspiratory coarse crackles of left base, hyperinflated chest, using accessory muscles for respiration. HR 116, BP 109/76. Alert, BM normal. Temp 37.9. ABG shows a respiratory acidosis. What is the diagnosis?
Infective exacerbation of COPD
Type 2 respiratory failure
What is the management for an infective exacerbation of COPD?
Controlled oxygen therapy – replacing non-rebreathe if used with venturititrated to maintain O2 sats 88-92%
Nebulisers (Ipratropium/ salbutamol)
Prednisolone
Abx
Which COPD patients should be considered for NIV?
All patients with an acute exacerbation of COPD in whom a respiratory acidosis (PaCO2>6kPa, pH <7.35 >7.26) persists despite immediate maximum standard medical treatment on controlled oxygen therapy for no more than one hour
What are common causes of type 1 respiratory failure?
Pneumonia
PE
Asthma
Pulmonary fibrosis
What is the management for PE?
O2 – titrate to maintain sats 94-98%
Enoxaparin treatment dose 1.5mg/kg
CTPA
What is the definition of chronic bronchitis?
Sputum production on most days for at least 3 months of the year for at least 2 years
What are the 2 tests for TB and when are they used?
Mantoux - purified protein derivative injected intradermally, result read 2-3 days later
Interferon gamma blood test used if mantoux is positive or unequivocal or in people where tuberculin test may be false negative - miliary TB, sarcoidosis, HIV, lymphoma, less than 6 months old
What is hypertrophic osteoarthropathy?
Periosteal reaction involving long bones of distal extremities without underlying bone lesion
Clubbing of fingers when associated with a pulmonary condition, it is termed hypertrophic pulmonary osteoarthropathy (HPOA) and when associated with cancer is considered a paraneoplastic syndrome
Which type of lung cancer is associated with hypercalcaemia?
Squamous cell carcinoma
Due to parathyroid hormone related peptide release
What is a ghon complex?
Ghon focus: tubercle laden macrophages develops small lung lesion
This combined with hilar lymph nodes is a ghon complex
What are the possible sites for secondary tuberculosis?
Lungs CNS: tuberculous meningitis Vertebral bodies: Potts disease Cervical lymph nodes: scrofuloderma Renal GI tract
What 2 features define finger clubbing?
Loss of obtuse angle between the nail and dorsum of the finger
Thickening of the nail bed
What are the respiratory causes of finger clubbing?
Carcinoma of the bronchus Pulmonary fibrosis Brochiectasis Empyema/lung abscess Asbestosis/mesothelioma
What is pickwickian syndrome?
Obesity hypoventilation syndrome
Failure to breathe rapidly or deeply enough resulting in low sats and high CO2 levels
Commonly associated with OSA
When is latent TB treated in HIV positive patients?
What is the treatment?
If positive test for latent TB
If contact with sputum positive person
Past history of untreated TB
Isoniazid orally for 9 months
What is hypertrophic pulmonary osteoarthropathy?
Clubbing and periostitis of the small hand joints especially the DIPs and MCPs
Distal expansion of long bones and painful swollen joints
Can be primary but also secondary to lung cancer
What are extrapulmonary manifestations of mycoplasma pneumonia?
Haemolytic anaemia Renal failure Hepatitis Myocarditis Meningism and meningitis Transverse myelitis Cerebellar ataxia
What are management options for obstructive sleep apnoea?
CPAP
Weight loss
Smoking cessation
What is caplans syndrome?
Combination of RA and pneumoconiosis that manifests as intrapulmonary nodules on chest X-ray
How is aspergilloma diagnosed?
Presence of serum antibodies against Aspergillus fumigatus
Mycological examination of sputum
What is hyatid disease of the lung? How is it treated?
Caused by echinococcus granulosus
When humans ingest embryo of dog tapeworm
Cause hyatid cysts which can form in liver, lung, kidneys and brain
Treat with albendazole
What are the rules on driving HGVs with obstructive sleep apnoea?
Cease driving until stable on therapy - CPAP
Required to have annual review
What is the next step for COPD patients who remain breathless or have exacerbations despite using short acting bronchodilators?
FEV1 >50%: long acting beta agonist or long acting muscarinic antagonist
FEV1 <50%: LABA and ICS or LAMA
In which lung cancer patients would a pet scan be useful?
Non small cell cancer to establish eligibility for curative treatment
What are indications for non invasive ventilation?
COPD with resp acidosis 7.25-7.35
Type 2 resp failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
Cardiogenic pulmonary oedema unresponsive to CPAP
Weaning from tracheal intubation
What is the most common form of asbestos related lung disease?
Pleural plaques
What are features of cystic fibrosis?
Bronchiectasis Infertility Recurrent pancreatitis Biliary cirrhosis Nasal polyps Pneumothorax
What condition causes fluffy nodular shadowing, streaky shadows particularly in upper zones on chest X-ray?
Hypersensitivity pneumonitis
What are indications for long term oxygen therapy?
p02 less than 7.3 Or those with 7.3-8 plus: Secondary polycythemia Nocturnal hypoxaemia Peripheral oedema Pulmonary HTN
What signs on examination are suggestive of a PE?
Tachycardia Tachypnoea Hypotension Gallop rhythm Raised JVP Loud second heart sound in pulmonary area Right ventricular heave Pleural rub Cyanosis Atrial fibrillation
What ECG changes can be seen with a PE?
Normal Sinus tachycardia Right ventricular strain in V1-V3 Right axis deviation Right bundle branch block Atrial fibrillation Deep S waves in I Q waves in III Inverted T waves in III
What is the management algorithm for COPD?
Mild FEV 80% predicted or more: active reduction of risk factors, flu vaccine, SABA
Moderate FEV between 50 and 79% predicted: add regular LABA and rehab
Severe FEV between 30 and 49% predicted: add inhaled glucocorticoids if repeated exacerbations
Very severe FEV less than 30% predicted/resp failure: add long term 02, consider surgery
Who should be offered the BCG vaccine?
All infants 0-12 months living in areas of UK where annual incidence of TB is more than 40/100000
All children with parent or grandparent who was born in country with annual incidence over 40/100000 (if 6 or more need tuberculin test first)
Previously unvaccinated tuberculin negative contacts of resp TB cases
Previously unvaccinated tuberculin negative new entrants to UK under 16 who were born in/lived in country with high incidence
Healthcare workers
Prison staff
Staff of care home for elderly
Those who work with homeless people
What are contraindications to BCG vaccine?
Previous BCG Past Hx of TB HIV Pregnancy Positive tuberculin test (heaf or mantoux)
What are common causes of lobar collapse?
Lung cancer
Asthma (mucous plugging)
Foreign body
What investigations should be performed for a patient with suspected TB?
Chest X-ray Sputum smear for acid fast bacilli Sputum culture (3 samples) Tuberculin skin testing FBC Lymph node fine needle aspiration Pleural fluid analysis by thoracocentesis HIV test
What are important management steps for a patient with confirmed active TB?
Notify PHE
Antibiotics: 6 months RI, 2 months with PE
Contact tracing
Direct observed therapy if considered high risk poor adherence
What is idiopathic pulmonary artery hypertension? How does it present?
Pulmonary artery pressure >25 at rest, >30 with exercise
Diagnosed when no underlying cause can be found
More common in females
Progressive SOB
Cyanosis
Right ventricular heave, loud P2, raised JVP with prominent a waves, tricuspid regurgitation
What is the management of idiopathic pulmonary artery hypertension?
Echo Diuretics if right heart failure Anticoagulation Vasodilator therapy: calcium channel blocker, IV prostaglandins, bosentan (endothelin 1 antagonist) Heart lung transplant
What is lights criteria for distinguishing between transudate and exudate?
Protein: exudate >30, transudate <30
If between 25-35 use criteria
Exudate likely if: fluid/serum ratio protein >0.5, fluid/serum LDH >0.6, fluid LDH >2/3 upper limit of normal serum
Which patients should be assessed for the need for LTOT in COPD?
Very severe airway obstruction: FEV1 <30% predicted Cyanosis Polycythemia Peripheral oedema Raised JVP Sats 92% or less on air
Which patients with COPD should be offered LTOT?
PO2 <7.3 on two occasions at least 3 weeks apart
Or PO2 of 7.3-8 and one of: secondary polycythemia, nocturnal hypoxaemia, peripheral oedema, pulmonary HTN
What is the commonest neurological manifestation of sarcoid?
Facial nerve palsy
What are predisposing factors for OSA?
Obesity
Macroglossia: acromegaly, hypothyroidism, amyloidosis
Large tonsils
Marfans
What is the management of OSA?
Weight loss
CPAP first line for moderate or severe
Intra oral devices (mandibular advancement)
What are advantages and disadvantages of metered dose inhalers?
Cheap, quick and convenient to use
Needs good co-ordination
Poor inhaler technique is common
When used correctly only 10%-20% of the drug reaches lungs
What are advantages and disadvantages of using a spacer device with an MDI?
Holds drug like reservoir
Removes need for co-ordination of breathing and actuation
Pharyngeal deposition is greatly reduced
Smaller particles penetrate further into lungs depositing agreater proportion of drug
Available with mask
Electrostatic charge reduces delivery
What are advantages and disadvantages of breath activated MDIs?
Spring mechanism is triggered by inspiratory flow rate of 22-36 L/m
Drug delivery less dependent on technique
When cap is removed inhaler is primed and ready to fire
Generally bigger than MDIs
What are advantages and disadvantages of dry powder inhalers?
Inspiratory airflow releases fine powder (therefore no co-ordination needed)
Inspiratory flow rate needed - may be a problem with some devices
Turbohalers have no taste, hence there could be uncertainty it has been taken by the patient
Turbohalers delivers 20%-30% of drug
Accuhalers deliver 11%-15% of drug
Not suitable for young children
What are side effects of steroid inhalers?
Sore throat/hoarse voice
Oral thrush
Higher risk of osteoporosis with long term use of high dose steroids
What are benefits of maintenance and reliever therapy as combined inhalers?
Helps to overcome poor adherence with ICS
Can reduce risk of asthma attacks requiring oral steroids in
patients who are not controlled on maintenance ICS alone (with separate relief medication)
Reduces number of inhalers a patient needs
What do the BTS guidelines say about use of MART therapy?
For adults over age of 18, combined maintenance and reliever therapy can be considered for patients who have a history of asthma attacks on medium dose ICS or ICS/LABA
What are examples of MART inhalers?
Symbicort: budesonide/formoterol 6microg formulations (200/6 or 100/6). 1-2 puffs BD + 8 additional puffs as maintenance (max 12 puffs)
Duoresp: 6microg formulation (200/6). 1-2 puffs BD + 8 additional puffs as maintenance (max 12 puffs)
Fostair: 6microg formulation (100/6). 1-2 puffs BD + 6 additional puffs as maintenance (max 10 puffs)
What are indications for steroids in sarcoidosis?
Parenchymal lung disease
Uveitis
Hypercalcaemia
Neurological or cardiac involvement
What are complications of lung tumours?
Recurrent laryngeal nerve compression SVCO Horners Rib erosions Pericarditis AF Mets: bone, brain, liver, adrenals Ectopic hormones: SIADH, ACTH
What are complications of staphylococcal pneumonia?
Air cavity (pneumatocele) Air leaks (pneumothorax, pneumomediastinum, subcuteneous emphysema) Necrotizing Pneumonia (PVL-Panton-Valentine Leukocidin producing S. aureus)
What are extrapulmonary manifestations of mycoplasma pneumonia?
Ear infection Cervical lymp nodes Urticaria Erythema multiforme Autoimmune Haemolysis
What are risk factors for viral pneumonia?
Smoking exposure
Poor socioeconomic status
Pre-existing chronic conditions (CF, CLD, CHD, immunodef)
What are viral causes of pneumonia?
Influenza A and B Parainfluenza RSV HMV (humanemetapnemovirus) Adenovirus Rhinovirus Varicella CMV
What does viral pneumonia look like on a chest X-ray?
Non specific , widespread infiltrate rather than lobar
What is ABPA?
Allergic bronchopulmonary aspergillosis
Hypersensitivity response to fungus aspergillus, commonly in patients with asthma or cystic fibrosis
Features: eosinophilia, raised serum IgE, transient pulmonary infiltrate on chest X-ray, microscopically detectable hyphae of A. Fumigatus
What is Williams Campbell syndrome?
Deficiency of bronchial cartilage Persistent cough Wheeze Impaired lung function Overinflated lungs Bronchomalacia
A 45 year old asthmatic presents with night time wheezing and coughing despite being on regular beclometasone (400 micrograms/day) inhaled steroids, what is the next step?
Long acting beta 2 agonist
If a patient struggles with using a metered dose inhaler, what could be offered as alternative?
Breath actuated device: accuhaler, easibreathe, turbohaler
Haleraid (device to place over MDI to aid if impaired strength in hands)
Spacing device
Which inhaled drugs are useful for preventing exercise induced bronchospasm?
Leukotriene receptor antagonists
What are causes of bilateral hilar lymphadenopathy?
TB
Lymphoma
HIV
Sarcoid
What are the antibodies targeted against in goodpastures disease?
Basement membrane collagen
How is goodpastures managed?
Immunosuppressants
Plasma exchange
Renal support
What are complications of mycoplasma pneumonia?
Meningoencephalitis Polyneuritis Monoarticular arthritis SJS Myocarditis Hepatitis DIC Haemolytic anaemia
What is hypersensitivity pneumonitis?
Extrinsic allergic alveolitis
Inflammation of alveoli due to hypersensitivity to organic dusts
Usually hobby or occupation induced, symptoms relieved when away from precipitating factor
What might be seen on X-ray and pulmonary function tests in extrinsic allergic alveolitis?
Diffuse nodular interstitial pattern with ground glass appearance in lower and middle zones
Reduced diffusion capacity of lungs for carbon monoxide
What is the most common site for aspiration pneumonia? What clinical findings might you expect?
Right lower lobe
Bronchial breathing at right base due to consolidation of alveoli allowing superior transmission of sounds through bronchi and bronchioles to periphery of lung
What sound might be heard if there is a bronchial tumour in a lung?
Monophonic wheeze - mass partially obstructing airway
What lung sounds would be expected in idiopathic pulmonary fibrosis?
Fine inspiratory bibasal crackles
What sounds would be expected in a haemothorax?
Stony dullness to percussion
Absent breath sounds
What are the main indications for placing a chest tube in pleural infection?
Patients with frankly purulent or turbid/cloudy pleural fluid on sampling
Presence of organisms identified by Gram stain and/or culture from non purulent pleural fluid sample
Pleural fluid pH <7.2 in patients with suspected pleural infection
What should a pleural aspirate be sent for?
pH Protein LDH Cytology Microbiology
What is lights criteria?
Exudate protein >30
Transudate <30
If protein between 25-35 apply lights criteria. Exudate likely if:
Pleural fluid protein/serum >0.5
Pleural LDH/serum >0.6
Pleural LDH more than 2/3 upper limits of normal serum
How should COPD be managed?
Smoking cessation advice Annual flu vaccine One off pneumococcal vaccine SABA or SAMA first line FEV1 >50%: LABA or LAMA FEV1 <50%: LABA and ICS combo or LAMA Then if LABA, switch to LABA and ICS Give LAMA and LABA and ICS combo Theophylline after trials of long acting or if inhaled therapy not tolerated Mucolytics if chronic productive cough
What are the TB drugs and their mechanisms of action?
Rifampicin: inhibits DNA dependent RNA polymerase preventing transcription
Isoniazid: inhibits mycolic acid synthesis
Pyrizinamide: inhibits fatty acid synthase
Ethambutol: inhibits polymerisation of arabinose
What are side effects of TB drugs?
Rifampicin: liver inducer, hepatitis, orange secretions, flu like symptoms
Isoniazid: peripheral neuropathy, hepatitis, agranulocytosis, liver inhibitor
Pyrizinamide: hyperuricaemia (gout), arthralgia, myalgia, hepatitis
Ethambutol: optic neuritis
What is the latent period of asbestosis from time of exposure?
15-30 years
Where is the fibrosis in asbestosis?
Lower lobe fibrosis
Which is the most dangerous form of asbestos for causing mesothelioma?
Crocidolite (blue) asbestos
What are possible features of mesothelioma?
Progressive shortness of breath
Chest pain
Pleural effusion
What is the median survival from diagnosis of mesothelioma?
8-14 months
What different pathologies of the lung can be caused by asbestos?
Pleural plaques (benign)
Pleural thickening
Asbestosis
Mesothelioma
What is bronchiectasis?
Permanent dilatation of airways secondary to chronic infection or inflammation
What is management for bronchiectasis?
Assess for treatable cause (immune deficiency etc)
Physical training (inspiratory muscle training)
Postural drainage
Antibiotics for exacerbations, long term rotating abx in severe cases
Bronchodilators
Immunisations
Surgery
What are the most common organisms isolated from patients with bronchiectasis?
Haemophilus influenzae
Pseudomonas aeruginosa
Klebsiella
Strep pneumoniae
Which drugs can cause pulmonary fibrosis?
Amiodarone Bleomycin Methotrexate Sulfasalazine Gold Nitrofurantoin Bromocriptine Cabergoline
What is an essential study before a CTPA in PE?
Chest X-ray
What are differences in emphysema findings in alpha 1 antitrypsin deficiency and COPD?
Alpha 1 antitrypsin: lower lobe emphysema
COPD: upper lobe emphysema
What is alpha 1 antitrypsin deficiency?
Inherited condition caused by lack of protease inhibitor normally produced by liver
Panacinar emphysema marked in lower lobes
Liver cirrhosis and hepatocellular carcinoma
Cholestasis in children
What is management of alpha 1 antitrypsin deficiency?
No smoking
Supportive: bronchodilators, physiotherapy
IV alpha 1 antitrypsin protein concentrates
Surgery: volume reduction surgery, lung transplant
What are the antibiotics of choice for whooping cough?
Less than 1 month old: clarithromycin
Age 1 month or older: azithromycin or clarithromycin
Pregnant women: erythromycin
Which causes of fibrosis typically affect lower zones?
Idiopathic pulmonary fibrosis
Connective tissue disorders (except ank spond)
Drug induced: amiodarone, bleomycin, methotrexate
Asbestosis
Which causes of fibrosis typically affect the upper zones?
Extrinsic allergic alveolitis Coal workers pneumoconiosis/progressive massive fibrosis Silicosis Sarcoidosis Ank spond Histiocytosis TB
What features of asthma suggest poor control?
Having to use salbutamol over 3 times a week Reduced FEV1 Needing rescue medications Waking up at night with symptoms Interfering with life
What is the definition of COPD?
Chronic bronchitis: cough with sputum for most days for 3 months of 2 years
Emphysema: permanent dilatation with destruction of alveolar walls distal to terminal bronchioles
Less than 15% reversibility of FEV1 with bronchodilators
What are criteria for long term oxygen therapy?
Non smoker
PaO2 <7.3 in air
Or less than 8 in air with evidence of pulmonary HTN
What are causes of apical fibrosis?
EAA Ank spond Sarcoidosis TB Silicosis
What are causes of basal pulmonary fibrosis?
Idiopathic pulmonary fibrosis
Connective tissue disease
Asbestosis
Aspiration (recurrent)
Which drugs cause pulmonary fibrosis?
Amiodarone
Nitrofurantoin
Sulfasalazine
Methotrexate
What are treatments for CF?
Postural drainage Chest physio Active cycle breathing, flutter device Creon and fat soluble vitamins Immunisations DNase Antibiotics
What are causes of bronchiectasis?
Congenital: CF, hypogammaglobulinaemia, primary ciliary dyskinesia, kartageners, youngs
Post infectious: pertussis, ABPA, measles, recurrent aspiration, severe pneumonia, TB
Mechanical: foreign body, tumour
Other: RA, IBD, sjogrens, SLE, yellow nail syndrome
What causes pleural effusion?
Transudate: cardiac failure, renal failure, liver failure, hypoalbuminaemia
Exudate: parapneumonic, empyema, malignancy, inflammatory (RA, SLE)
What degree of reversibility do you expect to see in asthma on spirometry with bronchodilators?
> 15%
What are risk factors for obstructive sleep apnoea?
Obesity Acromegaly Enlarged tonsils/adenoids Nasal polyps Alcohol
What are management options for obstructive sleep apnoea?
Weight loss Avoid alcohol Sleep upright Mandibular advancement device CPAP Surgery (adenoidectomy)
What might sleep studies show in a patient with obstructive sleep apnoea?
At least 15 apnoeic episodes per hour of sleep
What are risk factors for pneumothorax?
Previous pneumothorax COPD Chronic lung disease: CF, alpha 1 antitrypsin Meds FH Smoking Cocaine Contact sports Scuba diver Planned flights
What does a swinging chest drain mean?
Drain is in pleural space
What advice should be given post pneumothorax?
Quit smoking Return if symptomatic Never scuba dive, unless pleurodesis Flights: if chest X-ray confirms no pneumothorax 7 days before flying Avoid contact sports for 6 weeks
What gives appearance of white out on chest X-ray?
Massive pleural effusion
Pneumonectomy
Total lung collapse
Who should be offered a FeNO test?
Adults in whom asthma is being considered
Children and young people (5-16) if diagnostic uncertainty after initial assessment
