Respiratory Flashcards
What is the pathophysiology of COPD?
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
What are the symptoms of COPD?
Productive cough of white/clear sputum, wheeze. SOB, frequent infective exacerbations, hypertension, osteoporosis, depression, weight loss and muscle wasting.
What are the signs of COPD?
Tachypnoeic with prolonged expiration, accessory muscles of respiration are used, cyanosis, hyperinflation, barrel shaped chest, cor pulmonale (increased JVP, RV failure)
What tests are used to diagnose COPD?
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
What treatment is used in COPD?
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
What is the aetiology of asthma?
Atopy and allergy
What is the pathophysiology of asthma?
Bronchial hyperresponsiveness, excessive smooth muscle contraction, hypertrophy and proliferation of smooth muscle cells, loss of ciliated columnar cells
What are the symptoms of asthma?
Wheezing attacks, episodic SOB, cough, nocturnal cough
What tests are used to diagnose asthma?
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
What is the treatment for asthma?
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
What is the cause of extrinsic allergic alveolitis?
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)
What is the pathophysiology of EAA?
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.
What are the symptoms of EAA?
Fever, malaise, cough, shortness of breath several hours after exposure
What are the signs of EAA?
Fever, tachypnoea, coarse-end inspiratory crackles and wheezes, cyanosis caused by V/Q mismatch. In chronic illness - weight loss, effort dyspnoea and cough.
What tests are done to diagnose EAA?
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
What is the treatment for EAA?
Avoid the provoking allergen.
Prednisolone 30-60mg daily may help to control symptoms
What is the definition of occupational lung disease?
A wide range of respiratory conditions caused by inhaling a harmful substance in the workplace
How are occupational lung diseases prevented?
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).
What are some of the causes of bronchiectasis?
Post-infective, congenital, loss of surrounding lung volumes, inhaled irritants, obstruction lesion, rheumatoid arthritis, IBD, connective tissue diseases, asthma, post-transplant and post-radiotherapy.
What is the pathophysiology of bronchiectasis?
Chronic inflammation is compounded by an inability to clear mucoid secretions which leads to permanent enlargement of parts of the airway.
What are the symptoms of bronchiectasis?
Cough, dyspnoea, chest pain, recurrent exacerbations and a long recovery time
What are the signs of bronchiectasis?
Haemoptysis, rarely pyrexial, finger clubbing, crepitations, deterioration in control of a previously stable lung condition.
What tests are used to diagnose bronchiectasis?
Spirometry - obstructive pattern
Sputum culture
CXR
High resolution CT
Immunology - functional antibodies, immunoglobulins
Bronchoscopy - rare
Functional ciliary investigations - specialist centres only
What is the treatment for bronchiectasis?
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
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)
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.
What are the symptoms of cystic fibrosis?
Poor growth, poor weight gain, frequent chest infections, coughing, dyspnoea
What are the signs of cystic fibrosis?
Meconium ileus in newborns, fatty stools, haemoptysis, pulmonary hypertension, hypoxia, nasal polyps, rectal prolapse, finger clubbing
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)
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
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
What are the symptoms of interstitial lung diseases?
Cough, dyspnoea, constitutional symptoms
What are the signs of interstitial lung diseases?
Finger clubbing, fine end inspiratory crepitations
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
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
What is the aetiology of sarcoidosis?
Unknown
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.
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
What are the signs of sarcoidosis?
Bilateral hilar lymphadenopathy, erythema nodosum, plaques, pulmonary infliltration
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)
What is the treatment for sarcoidosis?
NSAIDs, glucocorticoids, antimetabolites e.g. azathioprine, corticosteroids, infliximab and other anti-TNF agents
How is pulmonary hypertension defined?
A mean pulmonary arterial pressure of >25 mmHg at rest or >30 mmHg during exercise
What causes pulmonary hypertension?
COPD, pulmonary vascular disorders e.g. stenosis, MSK disorders (e.g. kyphoscoliosis), disturbance of respiratory control, cardiac disorders and SLE
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.
What are the symptoms of pulmonary hypertension?
Dyspnoea, fatigue, chest pain, palpitations, pain, poor appetite, lightheadedness, syncope and swelling
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
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.
What is the treatment for pulmonary hypertension?
To optimise left ventricle function - diuretics, digoxin, antiplatelets, sildenafil to treat pulmonary arterial hypertension
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.
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
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
What are the symptoms of pleural effusion?
Chest pain, cough, fever (if pneumonia is the cause), dyspnoea
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
What are the diagnostic tests for pulmonary effusion?
CXR - an area of whiteness, blunted costophrenic angles
CT chest
USS of the lung
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
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
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
What are the symptoms of a pneumothorax?
Chest pain, dyspnoea, hypoxaemia, cyanosis, hypercapnia, confusion (secondary to the hypercapnia)
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
What tests are used to diagnose a pneumothorax?
CXR - mediastinum shift
CT - very sensitive
USS
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
What are some causes of non-small cell lung cancer?
Smoking (80-90%), asbestos, radon, nickel refining
What is the pathophysiology of non-small cell lung cancer?
Squamous or epidermoid carcinoma, adenocarcinoma, large cell carcinoma.
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
What are the symptoms of NSCLC?
Cough, dyspnoea, wheeze, haemoptysis, dysphagia, hoarseness, chest pain, head, neck and arm swelling (SVC obstruction)
What are the signs of NSCLC?
Weight loss, finger clubbing, cyanosis
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
What is the treatment for NSCLC?
Surgery (<20% of NSCLC tumours are suitable)
Radical radiotherapy, chemotherapy, biological agents, immunotherapy
Concurrent radiotherapy and chemotherapy
What are some causes of small cell lung cancer?
Smoking (80-90%), asbestos, radon
What is the pathophysiology involved in small cell lung cancer?
SCLC arises from endocrine cells (Kulchitsky cells)
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
What are the symptoms of small cell lung cancer?
Cough, dyspnoea, wheeze, haemoptysis, dysphagia, hoarseness, chest pain, head, neck and arm swelling (SVC obstruction)
What are the signs of small cell lung cancer?
Weight loss, finger clubbing, syndrome of inappropriate secretion of ADH (SIADH), hypercalcaemia
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
What is the treatment for small cell lung cancer?
Chemotherapy, thoracic and cranial radiotherapy
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
How is NSCLC staged?
Using the TNM staging method
How is small cell lung cancer staged?
Limited diseases vs extensive disease
What is the aetiology of mesothelioma?
> 80% of mesothelioma is caused by asbestosis
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
What are the symptoms of mesothelioma?
Chest wall pain, dyspnoea, fatigue, wheeze, hoarseness, cough, haemoptysis
What are the signs of mesothelioma?
Pleural effusion, weight loss, PEs, night sweats
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
What is the treatment for mesothelioma?
Surgery - pleurectomy
Radiation
Chemotherapy - cisplatin +/- other drugs
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
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
What type of reaction is Goodpasture’s syndrome?
A type II hypersensitivity reaction
What are the symptoms of Goodpasture’s syndrome?
Cough, dyspnoea, chest pain, haemoptysis, fatigue, fever, chills, malaise, weight loss
What are the signs of Goodpasture’s syndrome?
Haematuria, proteinuria, hypertension, oedema, uraemia
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
What is the treatment of Goodpasture’s syndrome?
Plasmapheresis, immunosuppressant drugs e.g. cyclophosphamide, prednisone, rituximab, azathioprine
What is the aetiology of Wegener’s granulomatosis?
It is unknown
What is the pathophysiology involved in Wegener’s granulomatosis?
Inflammation with granuloma formation against a non-specific background
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
What are the signs of Wegener’s granulomatosis?
Rapidly progressive glomerulonephritis, rhinitis, scleritis, uveitis, episcleritis, conjunctivitis, subglottal stenosis, coin lesions, pulmonary infiltrates
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
What is the treatment for Wegener’s granulomatosis?
Cyclophosphamide and high dose corticosteroids, rituximab, less toxic immunosuppressants e.g. azathioprine, methotrexate, mycophenolate mofetil
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
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
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)
What are the signs of a PE?
Pleural rub over the affected area, pleural effusion, raised JVP and symptoms of shock
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
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
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
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
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
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
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
What are the common pathogens that cause pneumonia?
S. pneumoniae H. influenzae Influenza A virus Mycoplasma pneumoniae Legionella pneumophilia S. aureus (secondary to influenza)
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?
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.
What is the cause of upper respiratory tract infections?
They’re mostly viral e.g. rhinovirus, coronavirus, adenovirus, EBV or Influenza
What are the symptoms of an URTI?
Nasal discharge, nasal congestion, sneezing, sore throat, cough, fever, malaise, weakness, muscle pain
How are URTIs diagnosed?
Mostly through history and examination
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
What is the cause of TB?
It is caused by 4 main mycobacterial species: Mycobacterium tuberculosis Mycobacterium bovis Mycobacterium africanum Mycobacterium microti
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.
What is the epidemiology of TB?
It’s estimated 1/3 of the world’s population is infected with TB
What are some symptoms of TB?
Productive cough, haemoptysis, weight loss, fevers, sweats, hoarse voice, loss of appetite, pleuritic chest pain
What are some signs of TB?
Finger clubbing, pyrexia, pleural effusion, palpable lymph nodes - tender
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
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
What are some atypical causes of pneumonia?
Legionella pneumophilia
Chlamydophilia pneumoniae
Chlmydophilia psittaci
What are some risk groups for developing TB?
IVDUs, homeless patients, alcoholics, immunocompromised, Hep B and C
What other test is needed in TB positive patients?
HIV + Hep B/C screen
What is a side effect of rifampicin?
Red urine
What is a side effect of isoniazid?
Vitamin B6 deficiency - give vit B6 to prevent this
Peripheral neuropathy
