Respiratory Flashcards

Question

common causes of CAP

Answer 1

Common bacterial 1. strep pn up to 40% - esp splenetomy 2. haemophilus influenzae - mroe in copd 3. mycoplasma - erythema multiforme / marginatum + HAEMOLYSIS + bullous myringitis 4. Q fever - chlamydophila 5. legionella 6. pneumococcal 7. staph 8. moraxella catarrhalis 9. gram negs - aspiration Atypical Mycoplasma pneumococcal - liver dysfunction chlamydia C.psitacci C. burnetti Viral influenzae A/B

Answer 2

1. Abx amox and clarith +/- gram neg cover in aspiration 2. target sats and appropriate oxygen therapy 3. pen Ax - teicoplanin and clarith / flouroquinolone 6 week CXR + FU consider HIV screen based on presentation Vaccination

Answer 3

Hospital aquired pneumonia with Sx presenting >72 hours post admission USually gram neg org / pseudomonas

Answer 4

Permanent splinting open and destruction of middle and large bronchioles due to a) chronic infection or inflammation b) poor drainage c) airway obstruction (continued infection) d) defective immune response

Answer 5

Many causes! Surgical sieve V: vascular NONE ``` I: infective/inflammatory CYSTIC FIBROSIS FIBROSING PULMONARY ALVEOLITIS - ASPERGILLOUS TB HIV ``` ``` T: traumatic / mechanical - BRONCHIAL OBSTRUCTION COPD GRANULOMA - SARCOID TB CARCINOMA FOREIGN BODY LN COMPRESSION ``` A: autoimmune / OVERACTIVE / UNDERACTIVE ALLERGIC ASPERGILLOSIS A1 ANTITRYPSIN HYPOGAMMAGLOBULINAEMIA SCID HIV M: metabolic RECURRENT ASPIRATION I: iatrogenic/idiopathic N: neoplastic Bronchogenic cancer C: CONGENITAL CF Ypungs Syndrome - CF without CFTR D508 - middle age CP - aspiration YELLOW NAIL SYNDROME - yellow nails - abn lymphatics - pleural effusion (chylothorax) KARTAGENERS SYNDROME = PRIMARY CILIA DYSKINESIA: Dextrocardia / ciliary dyskinesia +bronchiectasis / otitis / subfertitily (similar to CF) A1 Antitrypsin

Answer 6

``` V: vascular I: infective/inflammatory T: traumatic A: autoimmune M: metabolic I: iatrogenic/idiopathic N: neoplastic C : congenital ```

Answer 7

CXR CYSTIC BRONCHIECTASIS Cystic sac distribution CYLINDRICAL BRONCHIECTASIS Tramlines / Ring shadowing Severe - see honeycombing - lots of ring shadowing showing fibroses / inflammed ``` HRCT - high sensitivity and specificity REID CLASSIFICATION Cylindrical - most advanced cystic SIGNET RING SIGN - bronchi 1.5x thickness of adjacent artery =Op Fluid levels in bronchi Mucus plugs - bronchocoeles ``` OBLITERATIVE BRONCHIOLITIS - TREE IN BUD APPEARANCE

Answer 8

HRCT - definitive CF GENOTYPING / SWEAT TEST >60mmol CL - AUT REC KARTAGENERS = primary ciliary dyskinesis - AUT REC TB - Tuberculin skin test / Quantiferon

Answer 9

CF transmembrane conductance regulator protein (CFTR) Transporter channel which regulates chloride ICM and ECM balance. Inhibits voltage gated Na channel from reabsorbing Na from ECM Therefore regulates water movement across cell membrane and therefore ECM viscosity via regulation of NaCL. Commonest mutation is DF508 - >90% Autosomal recessive When defective Chloride ions fail to be pumped back into cell eNAc not inhibited and as ECM Na > ICM - NA moves into cell Draws water by osmosis THEREFORE ECM becomes hyperviscos and high in CL concentration. - Frequently blocked ducts / poor clearance Basis of chloride sweat test >60mmol

Answer 10

Primary Ciliary Dyskinesia Presents akin to CF]]failure of clearance of any vesicle lined with cilia results in bronchiectasis chronic infection poor drainage airway obstruction

Answer 11

Form of obesity related lung disease Cluster of 1. OSA 2. Restrictive Pulm function tests 3. Nocturnal hyerpcapnia

Answer 12

``` Symptoms: daytime somnolence C02 retention headache on waking poor sleep witnessed apnoeas nocturnal waking Nocturia ``` ``` Signs neck collar >17.5cm shallow breathing pattern >50% - hypopnoea central cyanosis facial plethora - secondary polycythaemia crowded oropharynx hypo snoring ``` Associations: COPD Acromegally Ix: EPWORTH SLEEPINESS SCALE

Answer 13

Obstructive sleep apnoea - apnoeas and hypopnoeas The increased number of pauses/apnoeas >10secs in normal breathing pattern during sleep and /or reduction in normal tidal volume >50% with desaturation + sleep arousal 50% of OSA in patients who are NOT obese therefore underdiagnosed

Answer 14

OVERNIGHT POLYSOMNOGRAPHY FOLLOWED BY CPAP REPEAT with titration if confirmed. -sleep lab overnight A - Continous ECG / EEG / EMG / electro-oculogram -these determine stage of sleep cycle B - Resp effort + depth of ventilation = apnoeas ?central or obstructive C - microphone - snoring D - pulse oximetry E - body position DIAGNOSIS: Respiratory Disturbance Index = apnoeas/hour - >5 = abnormal - 5-15 = Mild - 5-30 = Moderate - >30 = Severe

Answer 15

Education Physio / Pulm rehab - expactoration training - PT - chest percussion / / forced expiration / posterior drainage - hypertonic saline nebs - CF or Kartageners - PEP devices - positive expiratory pressure / oscillating pep to aid removal and clearance of secretions Vaccination - influenza and pneumococcal (FEV1<40% or >65) - HiB Optimise nutrition -CF / alcohol / a1 antitrypsin / Kartageners may require CREON - start 25,000 with meals and 15,000 snacks Smoking Cessation - 5 As - assess smoker / advise to quit / assess readiness to quit / assist in quiting / arrange follow-up - CBT - Buproprion - Varenicline

Answer 16

Need very localised disease with otherwise good lung function 1. LUNG REDUCTION THERAPY excision of non functional lung allows for inflation / recruitment of trapped / physiologically normal lung REDUCES MORTALITY IMPROVES QOL REQUIREMENTS: TLCO >20% (diffusion capacity demonstrating functional lung tissue FEV1 >20% paC02 <7.3 i.e minimal evidence of T2RF ``` 2. Bullectomy excision of large bullae reduces risk of PTx restores elastic recoil reduces air resistance and air trapping increases functional residual capacity ``` REQUIREMENT: PROGRESSIVE DYSPNOEA FEV1<50% - GRADE 3 GOLD BULLAE >1/3 HEMITHORIAX WITH PRESERVED HISTOLOGY SURROUNDING 3. Lung Transplant for CF 1 year survival = 78% 5 year 51% REQUIREMENT: BODE >5 (BMI / MRC dyspn scale 1-5 / GOLD FEV1 (80/50/30) / 6 minute walk test)

Answer 17

Acute phase: Antibiotics Frequently colonised pseudomonas - Tazocin / Ciprofloxacin Steroids if focally wheezy Saline nebs -hypertonic nebs - CF or Kartageners Aminophyllin may also be indicated Chronic phase: Rescue pack of Abx Prophylactic Abx - regular rotations to avoid MDR - azithromycin or tobramycin / ciprofloxacin / doxycyclin / amoxicillin ICS - beclometasone - fluticasone Mucolytics - carbocisteine - glycopyronnium - RhDNAse Antibiotics if needed: Pseud - fully sensitive = ceftazidime / tobramycin resistance - pip taz / cipro Aspergillus - itroconazole and steroid

Answer 18

``` 1. Airway Chronic secretion burden Poor clearance Clubbing Chronic infections Rapidly colonised -->Develop bronchiectasis -permanent dilation of large and middle airways leading to poor drainage / chronic infection and inflammation / airway obstruction -OBSTRUCTIVE FLOW LOOP -REDUCED TCO / Kco ``` 2. Pancreatic insufficiency PD atresia / blockade results in Chronic pancreatitis -loss of exocrine function and endocrine function -Pancreatic autodigestion -multiple nutritional deficiencies due to loss of trypsin / amylase / lipase -Fatty vitamin deficiency - b12/folate / vit D / Vit E / Vit A CREON 25-50,000 TDS + 15-20,000 SNACKS PRN - ENDOCRINE INSUFFICIENCY - development of DM1 - insulin 3. Infertitility Juvenile atresia / resorption of Vas Deferens 4. Meconium ileus - fail to pass mec in first 24-48 hours of life - bowel obstruction can lead to definitive surgery in first week of life 5. Focal Biliary Cirrhosis + Portal HTN 6. Cholestasis and gall stones 7. Osteoporosis - Vit D and PTH production 8. Chronic sinusitis / ottitis / nasal polyposis

Answer 19

1. pseudomonas - late childhood 2. haemophilus influenza - early pre vacc 3. staph aureus - breast milk 4. BURKHOLDERIA CEPACIA COMPLEX - RARE - ACCELERATES DISEASE BURDEN - INCREASE MORTALITY - MAY BE A CONTRA-INDICATION TO TRANSPLANT

Answer 20

A rare complication of CF is colonisation with BURKHOLDERIA CEPACIA COMPLEX it accelerates disease burden may prevent transplant increases mortality

Answer 21

AV LE 32 years but increasing to 40 and still active

Answer 22

1. Recurrent CAP + assoc haemotysis - empyema / effusion 2. Reduced ET and QOL if poorly controlled 3. Pulmonary HTN - signet ring sign - fibrosed and thickened middle airway adjacent to pulmonary artery 4. core pulmonale and R sided HF 5. anaemia of chronic disease 6. DISSEMINATED INFECTION - STAPH SPINAL CORD ABSCESS - IE - CEREBRAL ABSCESS 7. SECONDARY AMYLOIDOSIS

Answer 23

ACTIVE / CHRONIC OR PAST INFECTION with mycobacterium Tuberculosis Acid Fast bacillus Mitosis in aerobic or anaerobic environments Very difficult to culture MDR and VDR forms are increasingly prevalent in Eastern Europe Typically acute infection presents with severe apical pneumonia with a GOHN focus on CXR which may have an internal fluid level demonstrating encapsulated abscess / caseating internal necrosis

Answer 24

1. Primary reactivation in an immunocompromised state - commencing chemotherapy - commencing biologic therapy specifically Tcell or anti-TNF e. g. infliximab / adalimumab / golimumab- anti-TNFa / vedolizumab - anti a4b7 integrin - T cell homing to gut / - HIV or HCV or EBV or HTLV 2. aspergillosis in old TB cavity 3. Metastatic infection - intestinal TB - cerebral TB - spinal TB 4. bronchiectasis - Lymphatic compression = poor drainage = bronchial stiffening + infection = fibrosis and stenosis 5.apical lung fibrosis

Answer 25

Theory - TB = air borne therefore aerobic so try and create a hypoxic environment to kill it FAILED AS TB CAN MITOSE IN AEROBIC + UNAEROBIC A) Phrenic nerve crush - supraclavicular scar -aim paralyse diaphragm on affected side to limit ventilation B) PLOMAGE - thoracotomy scar - Similar to pleuredesis but aim to fill chest cavity with inert substance on one side (VS stick pleura together) - wax / pingpong balls / gauze C) THORACOPLASTY - axillary scars / posterior scars / thoracotomy -Ribs removed to limit expansion

Answer 26

Chest deformity Cachexia high RR / IC or SC recession / Reduced Cricosternal distance scars - phrenic nerve crush / thoracotomy / drains Dullness to percusion Focal crackles Creps - fine end inspiratory - apical fibrosis or coarse expiratory bronchiectatic KYPHOSIS - SPINAL TB - POTTS = AKA GIBBUS DEFORMITY

Answer 27

AFB cultures x3 TB blood culture TB genotyping - see if MDR form ``` Mantoux - Tuberculin skin test -2 tuberculin units infiltrated SC -induces delayed hypersensiticity raction - TYPE IV -T cell mediated -View results 48-72 hours later <5mm NEGATIVE 5-14mm Positive >15mm strong positive <15mm if prior BCG count as negative ``` Quantiferon / T-SPOT- IFNy release assay Uses TB specific proteins and therefore more sensitive and specific than mantoux -CFP10 / ESAT-6

Answer 28

CFP10 / ESAT-6 are proteins specific to mycobacterium TB

Answer 29

Rheumatoid arthritis + pneumoconiosis

Answer 30

Persistent eosinophilia secondary to repeated parasitic infections results in hypersensitivity e.g. allergic eosinophillic asthma classic parasite = ascaris lumbricoides

Answer 31

``` Vascular PE Anti-GBM rarely IgA nephropathy - case reports microangiopathic granulomatosis - Wegners ``` Infective Pneumonia TB invasive aspergillosis - bad sign shows serious invasion Trauma iatrogenic chest drain metabolic antiphospholipid syndrome

Answer 32

Many causes Diagnosis: Haemoptysis Increased TLCO - reduced expiratory CO as prescence of blood in airway increases diffusion of CO into Hb High kCO - high transfer coefficient of CO for above reason look for blood in urine too for Glomerulonephritis lupus wegners anti GBM

Answer 33

1. often severe pneumonia 2. associated with haemolysis due to AI - anti-I vs rbc 3. erythema multiforme - target lesions 4. erythema nodosum - painful IgG deposits 5. bullous myringitis - blisters on tympani memb - PAIN

Answer 34

Tropical respiratory infection endemic to Thailand / N Australia causing cavitating pulmonary abscess, pleural effusions, vesicular eruptions over the shins, LFT derangement MORT 20-50% even with treatment Organism: BURKHOLDERIA PSEUDOMALLEI - gram neg bacteria Burkholderia CAPACCIA ALSO ACCELERATES DISEASE IN CF treatment: meropenem + cotrimoxazole

Answer 35

Erythema gyratum repens | CONCENTRIC ERYTHEMATOUS RINGS LIKE WOOD GRAINS

Answer 36

1. co-trimoxazole 2. dapsone note neither can be used in glucose 6 PD deficiency - rash - deranged LFTs Alt: Nebulised pentamidine Treatment Clindamycin

Answer 37

``` MOA: Slows conduction through AV node Targets multiple phsyiological receptors A1 receptor -negatively chronotropic -negatively dromotropic effects =Slows AV conduction =prolongation of the refractory period ``` Associtaed with significant bronchoconstriction when inhaled THEREFORE CONTRA IN ASTHMA IV VERAPAMIL CAN BE USED Resus council 1. vagal maneouvres - CS massage - bed tilt - blow into syringe - forced expiration raises pressure and decreases preload and increases afterload 2. adenosine 6/12/12 3. verapamil 2.5-5IV 4. DC cardioversion ``` Also contra: Asthma sick sinus syndrome AV and 3rd heart block ppm ```

Answer 38

Carcinoid - neuro endocrine tumour Bronchial carcinoid: -Arise from Kulchitskys cells in bronchial mucosa -secrete serotonin CXR: Central mass with focal lobular collapse Tracheal deviation / compression Presentation: Flushing / diarrhoea recurrent chest infections - CP and Wheeze Hoarse voice - recurrent laryngeal Pellagra (tumour takes up tryptophan and hypersecretes serotonin) (niacin deficiency) - dementia - diarrhoea - dermatitis SIADH - confusion / ataxia / hyponatraemia / thirst / fluid overload Bronchial carcinoid spectrum of NE tumours -SCLC most malignant -hypertrophic pulmonary osteoarthropathy =clubbing and periosteal reaction with wrist pain -SIADH -cerebellar degeneration - ANTI-HU antibodies - CUSHINGS -Age 50-70 ``` Diagnosis: HRCT BAL Biopsy Urine 5 hydroxyindoleacetic acid (urinary excreted serotonin metabolite) ``` Treatment = excision Symptoms : somatostatin analogues

Answer 39

Carcinoid syndrome describes metastases of carcinoid tumour.

Answer 40

Ceftazidime 2g IV Tobramycin PROPHYLAXIS: Nebulised Colistin (pyromyxin - mix of colisitin A+B active against gram negative bacilli) aminoglycosides RESISTANT: PIPERACILLIN AND TAZOBACTEM CIPROFLOXACIN MEROPENEM AND GENT

Answer 41

``` Remember COPD grading system GOLD = FEV1/FVC <70% 1 FEV1 >80% 2FEV1 50-80% 3 FEV1 30-50% 4FEV1 <30% or <50% + T2RF ``` ``` MRC dyspnoea scale 1 no restriction unless strenuous exercise 2 uphill SOB 3 slower pace but makes it 4 stops for breath after 100m 5 house restriced due to SOB ``` BRODE Index GOLD + MRC + 6 minute walk test + BMI ``` Asthma - no reduction in TCO >15% reversibility on bronchodilator Normal FVC Reduced FEV1 FEV1/FVC <70% Diurnal variation ``` COPD - reduced TO - no or very limited reversibility - FVC normal - FEV1/FVC <70% - expiratory plateau flow loop - normal inspiration IPLF- reduced TO May show mixed picture fo restriction and obstruction due to pulmonary fibrosis typically reduced TO and obstructive picture dominates EAA - reduced TO Another mixed picture due to allergic obstructive symtoms with superimpose fibrosis - typically apical does demo some reversibility but beclomet and salbutamol will have a very limited impact main feature is avoid triggers Pulmonary Haemorrhage - raised TO blood in alveoli presents a higher transfer opportunity for CO to displace CO2 and oxygen from haem anti-GBM / wegners with polyangitis / eosiniophillic granulomatosis and polyangitis (CHURG STRAUSS) Normal flow loop typically PE - reduced TO normal flow loop VQ mismatch

Answer 42

Work related variation in airway problems Wheeze and crackles intermittent pyrexia Over time - SOBOE - restrictive flow loop - limited reversibility - bronchiectasis and PF - clubbing - P.HTN + core pulmonale - ilanoprost + sildenafil + p.rehab - T2RF

Answer 43

``` Bibasal crackles myoglobinuria + proteinuria hyponatraemia leucocytosis LFT derangement ``` Mx: macrolides rifampicin ciprofloxacin / moxifloxacin

Answer 44

Hyponatraemia gastroenteritis Post Strep GN purpura GN Arthralgia Reactive arthritis GI upset Arthritis Urethritis

Answer 45

``` Severe CXR changes subacute presentation --> severe T1RF pleural effusion pericarditis GN Liver synthetic dysfunction erythema nodosum erythema marginatum ```

Answer 46

Postural drainage is getting in positions that make it easier for mucus to drain. Chest physiotherapy is gently "clapping" parts of the body to remove mucus from the lungs. They are often used together in conditions such as cystic fibrosis or a spinal cord injury (SCI) to help loosen and remove mucus from the lungs. DAILY FOR BRONCHIECTASIS

Answer 47

Triad of recurrently sterile exudative pleural effusion / lymphadeonpathy and dystrophic yellow nails caused by congenital abnormal lymphatic development Causes recurrent chest infections due to suppurative ineffective clearance of lymph progressing to bronchiectasis = subungal oedema / lymphoedema / pleural effusions

Answer 48

TUBERCULOUS SPONDYLITIS Secondary to extra-spinal infection - usually lungs or mediastinum ``` Spinal pain Spinal Rigidity Spinal Deformity Cold Abscess Vertebral collapse and paraplegia ``` Favours thoracic and lumbar vertebrate Invasion of Psoas also typically seen Late Xray changes: - Lytic destruction of anterior portion of vertebral body - Increased anterior wedging - Collapse of vertebral body - Reactive sclerosis on a progressive lytic process - Enlarged psoas shadow with or without calcification

Answer 49

Life threatening rapidly spreading cellulitis of SUBLINGUAL and SUBMANDIBULAR spaces that starts with an infected lower molar, If it spreads to SUPRAGLOTTIC tissues-->Risk of airway obstruction

Answer 50

Bronchiectasis subfertility Rhinosinusitis

Answer 51

SOBOE AND OSA

Answer 52

``` pancoast tumours are mainly squamous cell local invasion with late metastases horners phrenic nerve involvement recurrent laryngeal nerve involvement ``` heavily associated with smoking PTH related protein Activates osteoclasts increases absorption of Ca from PCT and gut increases phosphate excretion

Answer 53

rarely polymyositis - proximal weakness - ILD - conduction defects - foot drop Anti SRP antibodies

Answer 54

SIADH CEREBELLAR DEGENERATION AND ATAXIA -anti-Hu Abs CUSHINGS -hypertrophic pulmonary osteoarthropathy =clubbing and periosteal reaction with wrist pain

Answer 55

ACTH ectopic secretion alongside serotonin | note all carcinoid esp gastric associ with pellagra = dementia dermatitis diarrhoea death

Answer 56

Prophylactic antibiotics Creon postural drainage LUMACAFTOR increase translocation of CFTR proteins to the apical surface IVACAFTOR increase the number of open CFTR channels Terlipressin Modifies pulmonary blood flow and reduces haemotpysis LAMAs

Answer 57

NON PHARM ``` Smoking cessation Pulmonary rehab - clearance - exercise - nutrition - chest physio - anxiety management vaccinations - influenza - pneumococcal oxygen - LTOT prophylactic antibiotics lung reduction therapy - expand collapsed lung - bullectomy ``` PHARM - corticosteroids - Cyclophosphamide - Azathioprine - post transplant - Mycophenolate mofetil - post transplant - Nintedanib - anti-fibrotic targeting tyr kinases. Shown to slow the decline in lung function in mild-to-moderate IPF. - Pirfenidone

Answer 58

Omalizumab - Anti IgE Where conventional therapy has faied Mepolizumab - anti-IL-5 - anti - Th2 propogation used in IgE asthma where conventional therapies have faield

Answer 59

Montelukast is a leukotriene - 4 antagonist used int he treatment of childhood allerguc asthma as an adjuvant to inhaled therapy In adults its use is more limited but again as an adjuvant in allergic asthma Roflumilast is a PDE-4 inhibitor which is used to supplement inhaled therapy in the management of treatment resistant COPD AND BRONCHITIS - SEVERE WITH FEV1 <50% (GOLD) - >2 EXACERBATIONS DESPITE BEING ON TRIPLE THERAPY (LAMA / steroid / LABA)

Answer 60

10% of lung cancers are SCLC heavily associated with smoking - SIADH - CEREBELLAR DEGENERATION - ANTI-HU antibodies - CUSHINGS - HYPERTROPHIC PULMONARY OSTEOARTHROPATHY 85% are NSCLC comprising - adenocarcinoma - no paraneo - bronchio-alveolar - no paraneo - squamous cell skin cancer - PTHrP - hypercalcaemia 5% Carcinoid Neuroendocrine serotonin secreting Associated with Lambert eaton mysaesthenic syndrome VGCC Abs diff from MG as >excitation = >conduction due to >degranulation of ACh granules Also ?feature of autonomic symptoms like postural drops / incontinence / dry mouth and eyes / erectile dysfunction Autonomic features are rare in MG

Answer 61

Mycoplasma pneumonia see raised LDH marked reticulocytosis raised MCV due to high reticulocyte count low Hb

Answer 62

B2B salbutamol nebs ipratropium nebs IV hydrocortisone IV magnesium Limited evidence for aminophyllin in opening airway Evidence suggesting risk of taccharrythmia outweighs use non improvement psot these measures would be escalated to ITU for intubation and ventilation - PaO2 <8 - Resp acidosis / rising pCO2 - Fatigue - No improvement or very limited improvement in PEFR no place for NIV or CPAP

Answer 63

lambert eaton myaesthenic syndrome 50-70% underlying cancer mainly SCLC https://www.brainscape.com/packs presents as MG but slightly differently proximal weakness mainly legs / opthalmoplegia / loss of DTR 1. VGCC abs 2. greater facilitation on repeated contrction VS fatigue 3, greater autonomic features - erectile dys / postual drops / xeropthalmia or xerostoma

Answer 64

``` Apical Tb and aspergillosis / aspergilloma Ank spond Radiation Extrinsic allergic alveolitis Pneumoconiosis ``` ``` Basal CTD RA SLE MCTD SYSTEMIC SCLEROSIS IIP Asbestosis Aspiration ```

Answer 65

``` Steroids Panther trial proved increasrd comorbidity with azathioprine and steroid Immunosuppressants Ciclo RF gum hypertrophy and IS Bullectomy or lung sparing surgery FEV1 <50 >20 TLCO > 20 PAC02 <7.3 Apical disease Bullae >33% hemidiaphragm Antifibrotic agents PERFENIDONE for UIP WHEN FEV1 50-80 - poor steroid resp and 2.5 to 5yr mort Lung transplant - single lung (scar over good lung and crackles on contralateral side) ```