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Respiratory Flashcards

1
Q

What is the pathophysiology of COPD?

A

An increase in goblet cells, airway inflammation, airway fibrosis, luminal plugs and increased airway destruction. Loss of alveolar attachments and a decrease in elastic recoil. Blood vessels are damaged. There is V/Q mismatch, an increase in pulmonary artery pressure and a decrease in PaO2

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2
Q

What are the symptoms of COPD?

A

Productive cough of white/clear sputum, wheeze. SOB, frequent infective exacerbations, hypertension, osteoporosis, depression, weight loss and muscle wasting.

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3
Q

What are the signs of COPD?

A

Tachypnoeic with prolonged expiration, accessory muscles of respiration are used, cyanosis, hyperinflation, barrel shaped chest, cor pulmonale (increased JVP, RV failure)

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4
Q

What tests are used to diagnose COPD?

A

Spirometry, CXR, high resolution CT of the chest, ABG (hypoxaemia and hypercapnia), ECG, alpha 1 anti-trypsin levels and gentoype in premature disease or non-smokers

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5
Q

What treatment is used in COPD?

A

SABA (mild)
SABA & LABA or LAMA
SABA, ICS, LABA
SABA, ICS, LABA & LAMA (very severe)
Long term oxygen therapy in patients with chronic respiratory failure
Antibiotics in patients with exacerbations

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6
Q

What is the aetiology of asthma?

A

Atopy and allergy

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7
Q

What is the pathophysiology of asthma?

A

Bronchial hyperresponsiveness, excessive smooth muscle contraction, hypertrophy and proliferation of smooth muscle cells, loss of ciliated columnar cells

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8
Q

What are the symptoms of asthma?

A

Wheezing attacks, episodic SOB, cough, nocturnal cough

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9
Q

What tests are used to diagnose asthma?

A

Peak flow rate - diurnal variation
Spirometry - >15% improvement in FEV1 or PEFR following inhalation of a bronchodilator
Methacholine bronchial provocation test
Blood and sputum - increase in eosinophils
Trial of corticosteroids - >15% improvement in FEV1

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10
Q

What is the treatment for asthma?

A

SABA - mild
SABA & ICS
SABA, ICS & LABA
SABA, ICS, LABA and a 4th drug - very severe
In acute attacks: 40-60% O2, salbutamol neb +/- ipratropium neb, prednisolone+/- hydrocortisone, ABGs, CXR

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11
Q

What is the cause of extrinsic allergic alveolitis?

A

It is due to the inhalation of a number of different antigens, the most common are microbial spores contaminating vegetable matter (e.g. straw hay in Farmer’s lung)

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12
Q

What is the pathophysiology of EAA?

A

Widespread, diffuse inflammation in the small airways and alveoli. There is initial infiltration by neutrophils followed by T lymphocytes and macrophages. There are also small, non-caseating granulomas.

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13
Q

What are the symptoms of EAA?

A

Fever, malaise, cough, shortness of breath several hours after exposure

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14
Q

What are the signs of EAA?

A

Fever, tachypnoea, coarse-end inspiratory crackles and wheezes, cyanosis caused by V/Q mismatch. In chronic illness - weight loss, effort dyspnoea and cough.

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15
Q

What tests are done to diagnose EAA?

A

CXR - fluffy nodular shadowing
CT chest - ground glass opacity
Lung function tests - Restrictive ventilatory defect
Polymorphonuclear leukocyte count is increased in acute cases; precipitating antibodies
Increased T lymphocytes and granulocytes on bronchoalveolar lavage

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16
Q

What is the treatment for EAA?

A

Avoid the provoking allergen.

Prednisolone 30-60mg daily may help to control symptoms

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17
Q

What is the definition of occupational lung disease?

A

A wide range of respiratory conditions caused by inhaling a harmful substance in the workplace

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18
Q

How are occupational lung diseases prevented?

A

Preventing occupational lung disease is a legal requirement under COSHH. Can prevent or minimise exposures to harmful substances by elimination, substitution, engineering controls and respiratory protective equipment (RPE).

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19
Q

What are some of the causes of bronchiectasis?

A

Post-infective, congenital, loss of surrounding lung volumes, inhaled irritants, obstruction lesion, rheumatoid arthritis, IBD, connective tissue diseases, asthma, post-transplant and post-radiotherapy.

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20
Q

What is the pathophysiology of bronchiectasis?

A

Chronic inflammation is compounded by an inability to clear mucoid secretions which leads to permanent enlargement of parts of the airway.

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21
Q

What are the symptoms of bronchiectasis?

A

Cough, dyspnoea, chest pain, recurrent exacerbations and a long recovery time

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22
Q

What are the signs of bronchiectasis?

A

Haemoptysis, rarely pyrexial, finger clubbing, crepitations, deterioration in control of a previously stable lung condition.

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23
Q

What tests are used to diagnose bronchiectasis?

A

Spirometry - obstructive pattern
Sputum culture
CXR
High resolution CT
Immunology - functional antibodies, immunoglobulins
Bronchoscopy - rare
Functional ciliary investigations - specialist centres only

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24
Q

What is the treatment for bronchiectasis?

A

Improve mucus clearance - chest physio, mucolytics, hypertonic saline nebs, ?inhaled mannitol
Anti-microbial therapy
Anti-inflammatories - inhaled steroids and macrolide antibiotics
Bronchodilators
Embolisation of major haemoptysis
Thoracic surgery - very rare

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25
What is the cause of cystic fibrosis?
A defect in the long arm of chromosome 7 coding for the cystic fibrosis transmembrane regulator (CFTR) protein; delta F508 is the most common mutation (severe phenotype)
26
What is the pathophysiology involved in cystic fibrosis?
CFTR is a transport protein (chloride and thiocyanate ions) on epithelial cells. An abnormal CFTR results in dysregulated epithelial fluid transport leading to thickened secretions.
27
What are the symptoms of cystic fibrosis?
Poor growth, poor weight gain, frequent chest infections, coughing, dyspnoea
28
What are the signs of cystic fibrosis?
Meconium ileus in newborns, fatty stools, haemoptysis, pulmonary hypertension, hypoxia, nasal polyps, rectal prolapse, finger clubbing
29
What are the diagnostic tests for cystic fibrosis?
Genetic testing, sweat testing (increased NaCl in the sweat), clinical diagnosis (chronic sinopulmonary disease, GI and nutritional disorders, salt loss syndromes, male urogenital abnormalities)
30
What is the treatment for cystic fibrosis?
``` Prevention (hygiene, flu & pneumococcal vaccines) Segregation from other CF patients Prophylaxis - antibiotics Surveillance - annual review (nasal swab, cough swab and sputum sample) Eradication - high dose targeted combination antibiotics Suppression Aggressive treatment Anti-inflammatories Chest physio Supporting therapies Nutritional support Bilateral lung transplant ```
31
What is the classification of interstitial lung diseases?
Associated with systemic diseases e.g. Rheumatoid arthritis, vasculitis, vascular AVMs Caused by environmental triggers e.g. drugs, fungal, dusts Granulomatous disease e.g. Sarcoid, Wegener's granulomatous vasculitis Idiopathic e.g. idiopathic pulmonary fibrosis, non-specific interstitial pneumonia, desquamative interstitial pneumonia, cryptogenic organising pneumonia Other - lymphangiolyomyomatosis, eosinophilic pneumonia
32
What are the symptoms of interstitial lung diseases?
Cough, dyspnoea, constitutional symptoms
33
What are the signs of interstitial lung diseases?
Finger clubbing, fine end inspiratory crepitations
34
What are the diagnostic tests for interstitial lung diseases?
CXR - lung size, distribution of abnormalities, size and shape of abnormalities, confluent shadows, pleural disease and lymphadenopathy Lung function tests - Restrictive pattern, reduced gas transfer, low/normal PaO2 Bloods - FBC, U&Es, total IgE, ACE, ANA, ENA, dsDNA, rheumatoid factor, ANCA High resolution CT Broncho-alveolar lavage Lung biopsy
35
What is the treatment for interstitial lung diseases?
Transplant is the only treatment known to extend survival in IPF Stop smoking Some patients may need steroids
36
What is the aetiology of sarcoidosis?
Unknown
37
What is the pathophysiology involved in sarcoidosis?
Granulomatous inflammation is characterised primarily by an accumulation of monocytes, macrophages and activated T cells. Typical sarcoid granulomas consist of focal accumulations of epithelioid cells, macrophages and lymphocytes, mainly T cells.
38
What are the symptoms of sarcoidosis?
Fatigue, lack of energy, weight loss, joint aches and pains, arthritis, dry eyes, swelling of the knees, blurry vision, dyspnoea, dry hacking cough
39
What are the signs of sarcoidosis?
Bilateral hilar lymphadenopathy, erythema nodosum, plaques, pulmonary infliltration
40
What are the diagnostic tests for sarcoidosis?
Sarcoidosis is a diagnosis of exclusion. Diagnosis is made through clinical features, CXR (bilateral hilar lymphadenopathy), radiology and biopsy (not necessarily a lung biopsy)
41
What is the treatment for sarcoidosis?
NSAIDs, glucocorticoids, antimetabolites e.g. azathioprine, corticosteroids, infliximab and other anti-TNF agents
42
How is pulmonary hypertension defined?
A mean pulmonary arterial pressure of >25 mmHg at rest or >30 mmHg during exercise
43
What causes pulmonary hypertension?
COPD, pulmonary vascular disorders e.g. stenosis, MSK disorders (e.g. kyphoscoliosis), disturbance of respiratory control, cardiac disorders and SLE
44
What is the pathophysiology involved in pulmonary hypertension?
There is a narrowing of blood vessels connected to and within the lungs leading to hypertrophy of the right ventricle and RV failure.
45
What are the symptoms of pulmonary hypertension?
Dyspnoea, fatigue, chest pain, palpitations, pain, poor appetite, lightheadedness, syncope and swelling
46
What are the signs of pulmonary hypertension?
Cyanosis, oedema, haemoptysis, accentuated pulmonary component of the second heart sound, right ventricular third heart sound, parasternal heave
47
What tests are used to diagnose pulmonary hypertension?
Pulmonary function tests, CXR, bloods, ECG, ABG, echo and high resolution CT. Right heart catheterisation can confirm pulmonary hypertension.
48
What is the treatment for pulmonary hypertension?
To optimise left ventricle function - diuretics, digoxin, antiplatelets, sildenafil to treat pulmonary arterial hypertension
49
What is a pulmonary effusion?
An excessive accumulation of fluid in the pleural space. | It can be detected on CXR when >300ml of fluid; can be detected clinically when >500ml of fluid.
50
What is the aetiology of pulmonary effusion?
Transudate - heart failure, hypoproteinaemia, constrictive pericarditis Exudates - bacterial pneumonia, carcinoma of the bronchus, pulmonary infarction, TB, mesothelioma and sarcoidosis
51
What is the pathophysiology involved in pulmonary effusion?
Exudative effusions occur when the pleura is damaged e.g. by trauma or infection. Transudative effusions occur when there is excessive production of pleural fluid or the resorption capacity is exceeded
52
What are the symptoms of pleural effusion?
Chest pain, cough, fever (if pneumonia is the cause), dyspnoea
53
What are the signs of pleural effusion?
Decreased movement of the chest on the affected side Dullness to percussion Diminished breath sounds on the affected side Bronchial breathing above the effusion Tracheal deviation away from the effusion
54
What are the diagnostic tests for pulmonary effusion?
CXR - an area of whiteness, blunted costophrenic angles CT chest USS of the lung
55
What is the treatment for pulmonary effusion?
Thoracentesis to drain off the fluid +/- a chest drain | Treat the underlying cause of the pleural effusion e.g. pneumonia
56
What is the aetiology of a pneumothorax?
Primary - occur in the absence of lung disease, cause unknown Secondary - occur in the presence of lung disease e.g. COPD, CF, PCP, TB or cancer Trauma
57
What is the pathophysiology of a pneumothorax?
Air enters into the pleural space either through damage to the chest wall, damage to the lung or microorganisms in the pleural space produce gas
58
What are the symptoms of a pneumothorax?
Chest pain, dyspnoea, hypoxaemia, cyanosis, hypercapnia, confusion (secondary to the hypercapnia)
59
What are the signs for a pneumothorax?
Diminished breath sounds on the affected side Hyper-resonant on percussion Vocal resonance and tactile fremitus can be decreased
60
What tests are used to diagnose a pneumothorax?
CXR - mediastinum shift CT - very sensitive USS
61
What is the treatment for a pneumothorax?
Conservative treatment for small, spontaneous pneumothoraces if there's no dyspnoea or underlying lung disease - CXR at fortnightly intervals to confirm improvement Aspiration - large PSPs (>50%) or PSP associated with dyspnoea. Can remove up to 2.5L of air in adults. Chest tube - PSPs unresponsive to needle aspiration, large SSPs or tension pneumothorax Pleurectomy or talc pleurodesis if pneumothorax occurs more than twice
62
What are some causes of non-small cell lung cancer?
Smoking (80-90%), asbestos, radon, nickel refining
63
What is the pathophysiology of non-small cell lung cancer?
Squamous or epidermoid carcinoma, adenocarcinoma, large cell carcinoma.
64
How common in non-small cell lung cancer?
NSCLC accounts for 87% of all lung cancers and lung cancer is the third most common cancer in the UK
65
What are the symptoms of NSCLC?
Cough, dyspnoea, wheeze, haemoptysis, dysphagia, hoarseness, chest pain, head, neck and arm swelling (SVC obstruction)
66
What are the signs of NSCLC?
Weight loss, finger clubbing, cyanosis
67
What are the diagnostic tests for NSCLC?
``` CXR CT scan Bronchoscopy +/- USS guided biopsy CT guided percutaneous needle biopsy USS guided aspirate or biopsy Surgical biopsy ``` To assess resectability: bloods, CT thorax and abdo, PET scan, CT head, mediastinoscopy, pleural aspiration CT-PET to assess mediastinum and metastases To assess fitness for surgery: ECG, lung function, exercise capacity, performance status
68
What is the treatment for NSCLC?
Surgery (<20% of NSCLC tumours are suitable) Radical radiotherapy, chemotherapy, biological agents, immunotherapy Concurrent radiotherapy and chemotherapy
69
What are some causes of small cell lung cancer?
Smoking (80-90%), asbestos, radon
70
What is the pathophysiology involved in small cell lung cancer?
SCLC arises from endocrine cells (Kulchitsky cells)
71
How common is small cell lung cancer?
SCLC accounts for 12% of all lung cancers, lung cancer is the third most common cancer in the UK
72
What are the symptoms of small cell lung cancer?
Cough, dyspnoea, wheeze, haemoptysis, dysphagia, hoarseness, chest pain, head, neck and arm swelling (SVC obstruction)
73
What are the signs of small cell lung cancer?
Weight loss, finger clubbing, syndrome of inappropriate secretion of ADH (SIADH), hypercalcaemia
74
What are the diagnostic tests for small cell lung cancer?
``` CXR CT scan Bronchoscopy +/- USS guided biopsy CT guided percutaneous needle biopsy USS guided aspirate or biopsy Surgical biopsy CT-PET to assess mediastinum and metastases ```
75
What is the treatment for small cell lung cancer?
Chemotherapy, thoracic and cranial radiotherapy
76
What is the prognosis for small cell lung cancer?
Limited disease: no treatment - 9-12 months, with treatment - 12-15 months Extensive disease: no treatment - 1-3 months, with treatment - 6-9 months
77
How is NSCLC staged?
Using the TNM staging method
78
How is small cell lung cancer staged?
Limited diseases vs extensive disease
79
What is the aetiology of mesothelioma?
>80% of mesothelioma is caused by asbestosis
80
What is the pathophysiology involved in mesothelioma?
The mesothelium is a single layer of flattened to cuboidal cells. Deposition of asbestos fibres in the lung parenchyma results in malignant mesothelial plaques
81
What are the symptoms of mesothelioma?
Chest wall pain, dyspnoea, fatigue, wheeze, hoarseness, cough, haemoptysis
82
What are the signs of mesothelioma?
Pleural effusion, weight loss, PEs, night sweats
83
What tests are used to diagnose mesothelioma?
CXR - pleural thickening Lung function tests CT or MRI Aspiration of fluid if pleural effusion is present Biopsy - immunohistochemistry helps diagnose mesothelioma vs. other malignancies
84
What is the treatment for mesothelioma?
Surgery - pleurectomy Radiation Chemotherapy - cisplatin +/- other drugs
85
What is the aetiology of Goodpasture's syndrome?
The precise cause is unknown. It could be exposure to organic solvents and hydrocarbons, bacteraemia, sepsis, infection e.g. influenza A, cocaine inhalation
86
What is the pathophysiology involved in Goodpasture's syndrome?
Abnormal production of anti-GBM antibodies, the antibodies attack the alveoli and glomeruli basement membranes which activate complement resulting in the death of tagged cells
87
What type of reaction is Goodpasture's syndrome?
A type II hypersensitivity reaction
88
What are the symptoms of Goodpasture's syndrome?
Cough, dyspnoea, chest pain, haemoptysis, fatigue, fever, chills, malaise, weight loss
89
What are the signs of Goodpasture's syndrome?
Haematuria, proteinuria, hypertension, oedema, uraemia
90
What tests are used to diagnose Goodpasture's syndrome?
CXR - transient blotchy shadows Biopsy and stain for anti-GBM antibodies Bloods - may be ANCA positive
91
What is the treatment of Goodpasture's syndrome?
Plasmapheresis, immunosuppressant drugs e.g. cyclophosphamide, prednisone, rituximab, azathioprine
92
What is the aetiology of Wegener's granulomatosis?
It is unknown
93
What is the pathophysiology involved in Wegener's granulomatosis?
Inflammation with granuloma formation against a non-specific background
94
What are the symptoms of Wegener's granulomatosis?
``` Rhinitis is the first symptom in most people Nose bleeds Cough Haemoptysis Pleuritic chest pain Joint pain Joint swelling ```
95
What are the signs of Wegener's granulomatosis?
Rapidly progressive glomerulonephritis, rhinitis, scleritis, uveitis, episcleritis, conjunctivitis, subglottal stenosis, coin lesions, pulmonary infiltrates
96
What tests are used to diagnose Wegener's granulomatosis?
Bloods - ANCA (suggests WG if positive but doesn't rule out Dx if negative) CXR - single or multiple nodular masses or pneumonic infiltrates with cavitation Biopsy - kidney or lung
97
What is the treatment for Wegener's granulomatosis?
Cyclophosphamide and high dose corticosteroids, rituximab, less toxic immunosuppressants e.g. azathioprine, methotrexate, mycophenolate mofetil
98
What is the aetiology for pulmonary embolisms?
Approx. 90% are from DVTs, <10% are from the right heart | Emboli are as a result of Virchow's triad
99
What is the pathophysiology involved in a PE?
The clot forms as a result of a combination of sluggish blood flow, local injury or compression of the vein and a hypercoagulable state
100
What are the symptoms of a PE?
Symptoms are typically sudden onset | Dyspnoea, tachypnoea, pleuritic chest pain and haemoptysis (only present when infarction has occurred)
101
What are the signs of a PE?
Pleural rub over the affected area, pleural effusion, raised JVP and symptoms of shock
102
What tests are used in the diagnosis of a PE?
CXR, ECG, D-dimer, Well's score, CTPA, V/Q scan Diagnosis can also be made through history and examination - a raised scoring system (e.g. Wells) score increases the probability of a PE
103
What is the treatment of a PE?
Heparin - unfractionated (IV) or low molecular weight (subcut) Novel oral anticoagulants e.g. apixaban, rivaroxaban Reperfusion - thrombolysis, IR or embolectomy Anticoagulation may need to be continued after the PE for up to 6 months or for life if the benefits outweigh the risks
104
What causes pneumonia?
It is usually caused by bacteria but can also be caused by chemical causes (e.g. aspiration of vomit), radiotherapy or allergic mechanisms
105
What is the pathophysiology of pneumonia?
Pneumonia frequently starts as an URTI, bacteria can be micro-aspirated and it's too much for the resident macrophages to phagocytose so infection takes over
106
What are the symptoms of pneumonia?
Fever, sweats, rigors, cough, sputum production, dyspnoea, pleuritic chest pain, systemic features e.g. weakness or malaise, extrapulmonary features e.g. GI
107
What are the signs of pneumonia?
Abnormal observations, dullness on percussion, decreased air entry, bronchial breath sounds, crackles +/- wheeze, increased vocal resonance, +/- hypoxia and signs of respiratory failure
108
What tests are used to diagnose pneumonia?
CXR Bloods - FBC, U&Es, LFTs, renal function, CRP Pulse oximetry Microbiological tests e.g. blood and sputum cultures ?ABG if suspecting respiratory failure
109
What are the common pathogens that cause pneumonia?
``` S. pneumoniae H. influenzae Influenza A virus Mycoplasma pneumoniae Legionella pneumophilia S. aureus (secondary to influenza) ```
110
What is the CURB65 score?
``` It predicts mortality and the implications of pneumonia C - Confusion? U - Urea >7 mmol/L R - RR >/=30 B - Systolic BP <90 or diastolic = 60 65 - is the patient >65? ```
111
What is the treatment for pneumonia?
CURB65 0-1: amoxicillin 500mg TDS PO or 500mg clarithromycin CURB65 2: amoxicillin and clarithromycin PO CURB65 3-5: IV co-amoxiclav 1.2g TDS + clarithromycin 500 mg BD The medication should last at least 5 days.
112
What is the cause of upper respiratory tract infections?
They're mostly viral e.g. rhinovirus, coronavirus, adenovirus, EBV or Influenza
113
What are the symptoms of an URTI?
Nasal discharge, nasal congestion, sneezing, sore throat, cough, fever, malaise, weakness, muscle pain
114
How are URTIs diagnosed?
Mostly through history and examination
115
What is the treatment for URTIs?
Antibiotics for probable bacterial URTIs - the Centor criteria give an indication of a sore throat being due to a bacterial infection
116
What is the cause of TB?
``` It is caused by 4 main mycobacterial species: Mycobacterium tuberculosis Mycobacterium bovis Mycobacterium africanum Mycobacterium microti ```
117
What is the pathophysiology involved in TB?
TB is an airborne infection spread via respiratory droplets. Only a small number of bacteria need to be inhaled for infection to develop.
118
What is the epidemiology of TB?
It's estimated 1/3 of the world's population is infected with TB
119
What are some symptoms of TB?
Productive cough, haemoptysis, weight loss, fevers, sweats, hoarse voice, loss of appetite, pleuritic chest pain
120
What are some signs of TB?
Finger clubbing, pyrexia, pleural effusion, palpable lymph nodes - tender
121
What tests are used to diagnose TB?
CXR - cavitation, pleural effusion or infiltrate, thickening or widening of the mediastinum Sputum samples - 3 spontaneous samples (1 early morning sample) for MC&S, stain with Ziehl-Neelsen stain. If sputum can't be obtained use induced sputum or bronchoalveolar lavage. Needle aspiration of lesions for non-respiratory TB
122
What is the first line treatment for TB?
RIPE | Six months of isoniazid and rifampicin supplemented in the first 2 months with pyrazinamide and ethambutol
123
What are some atypical causes of pneumonia?
Legionella pneumophilia Chlamydophilia pneumoniae Chlmydophilia psittaci
124
What are some risk groups for developing TB?
IVDUs, homeless patients, alcoholics, immunocompromised, Hep B and C
125
What other test is needed in TB positive patients?
HIV + Hep B/C screen
126
What is a side effect of rifampicin?
Red urine
127
What is a side effect of isoniazid?
Vitamin B6 deficiency - give vit B6 to prevent this | Peripheral neuropathy

Phase 2A (11 decks)

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