Respiratory Flashcards

Question

Causes of Bronchiectasis

Answer 1

**Congenital** Cystic fibrosis Primary ciliary dyskinesia (Kartagener's) Young's: azoospermia and bronchiectasis Hypogammaglobulinaemia: X-linked, CVID, specific antibody def **Acquired** Idiopathic Post-infectious: pertussis, TB, measles Obstructive: tumour, foreign body Associated: Rheumatoid arthritis, ulcerative colitis (and corhn's), ABPA

Answer 2

**Bedside** PEFR Urine dip: proteinuria ---\> amyloidosis **Sputum: M**C+S, cytology **Bloods** FBC: Serum Ig Aspergillus: RAST, precipitins, IgE, eosinophilia Precipitins: These tests detect the presence of IgG antibodies to Aspergillus fumigatus RA: anti-CCP. RF, ANA **Imaging** CXR: tramlines and ring shadows (bunch of grapes) HRCT: signet ring sign = thickended dilated bronchi and small adjacent vascular bundle Pools of mucus in saccular dilatations **Spirometry:** obstructive **Other** Bronchoscopy + biopsy CF sweat test Aspergillus skin prick testing

Answer 3

Cachexia Pulmonary HTN Massive haemoptysis Type 2 respiratory failure Amyloidosis

Answer 4

**MDT approach**: GP, Respiratory team, Dietician, Immunologist, Genetics **Physio:** Postural drainage Active cycle breathing Rehabilitation **Medical** Antibiotics: Ciprofloxacin for 7 days, Azithromycin for prophylaxis Bronchodilators: nebulised salbutamol **Treat underlying cause:** CF: DNAse, Creon, ADEK vitamins ABPA: steroids Immune def: IV Ig Vaccination: flue, pneumococcus

Answer 5

Autosomal recessive Mutation in **CFTR** gene on chromosome **7** Cystic fibrosis transmembrane conductase regulator Commonly **deltaF508** Deletion of three nucleotides = loss of phenylalanine (F) Decreased luminal CI- secretion and Increased Na resorption leading to viscous secretions Because chloride is negatively charged, this modifies the electrical potential inside and outside the cell that normally causes cations to cross into the cell. Sodium is the most common cation in the extracellular space. The excess chloride within sweat ducts prevents sodium resorption by epithelial sodium channels and the combination of sodium and chloride creates the salt, which is lost in high amounts in the sweat of individuals with CF. This lost salt forms the basis for the sweat test. CFTR not only allows chloride ions to be drawn from the cell and into the ASL, but it also regulates another channel called ENac, which allows sodium ions to leave the ASL and enter the respiratory epithelium. CFTR normally inhibits this channel, but if the CFTR is defective, then sodium flows freely from the ASL and into the cell. As water follows sodium, the depth of ASL will be depleted and the cilia will be left in the mucous layer Bronchioles --\> bronchiectasis Pancreatic duct --\> DM, malabsorption GIT --\> Distal intestinal obstruction syndrome Liver --\> gallstone, cirrhosis Fallopian tubes ---\> decrease female fertility Seminal vesicles ---\> Male infertility

Answer 6

Immunoreactive trypsinogen on heel-prick (neonatal screening) AND Sweat test \>60mM Cl- = diagnostic (false positive in hypothyroidism and Addison's) Faecal elastase - test of pancreatic exocrine function

Answer 7

**Bloods** FBC, LFTs, clotting, ADEK levels, GGT **Sputum**: MC+S **CXR** Diffuse tramlines and rings **Abso USS** Fatty liver, cirrhosis, pancreatitis **Spirometry** Obstruction Aspergillus serology / skin prick test (20% develop allergic bronchopulmonary aspergillosis)

Answer 8

**MDT:** GP, Gastroenterologist, Chest, Physio, Dietician, Specialist nurse Portacath insertion **Physio** Postural drainage Active cycle breathing **Chest** Antibiotics: Prophylaxis and Acute Mucolytics: DNAse Segregation from other CF patients, reduce risk of pseudomonas and burkholderia transmission Advanced disease ==\> heart lung transplant **GI** Creon Overnight feeds to increase nutrition ADEK supplements Insulin **Other** Fertility and genetic counselling DEXA and osteoporosis screen Mx complicatiosn e.g. DM Mean survival 35 years

Answer 9

**Autosomal recessive** defect in **ciliary motility** Poor mucociliary clearance --\> chronic recurrent inflammation and bronchiectasis Decreased sperm motility in males --\> infertility **Kartagener's Syndrome:** Situs invertus + Primary ciliary dyskinesia Situs invertus Chronic sinusitis Bronchiectasis

Answer 10

Bronchiectasis Rhinosinusitis Azospermia (no sperm in semen) --\> inferility

Answer 11

Very rare Yellow dystrophic nails Pleural effusions Lymphoedema: lymphatic hypoplasia Bronchiectasis

Answer 12

**ABPA** Type 1 and Type 3 hypersensitivity reaction to Aspergillus fumigatus Causes bronchoconstriction ---\> Bronchiectasis **Presentation** Dyspnoea Wheeze Cough Bronchiectasis **Invx** Increased IgE and eosinophilia positive IgG precipitins (not as positive as in aspergilloma) +ve skin prick test or RAST CXR **Mx** Prednisolone Itraconazole is sometimes introduced as a second line agent Bronchodilators

Answer 13

**Inspection** Chest drain **Evidence of cause:** Cancer: clubbing, cachexia, LNs Pneumonia: febrile CCF: increased JVP, S3, ascites, ankle oedema CLD: clubbing leukonychia, spider naevi, gynaecomastia CTD: rheumatoid hands, malar rash **Chest** Tracheal shift away from effusion Decreased expansion on the affacted side Stony dull percussion Recuded air entry Reduced tactile fremitus Significant negatives: Fever, Clubbing, Peripheral oedema, CTD

Answer 14

**Consolidation:** bronchial breathing + crackles **Collapse:** Increased VR

Answer 15

Transudate and Exudate **Transudate: bilateral, protein\<25g/L** Three failures, a thyroid and a meig CCF Renal fialure Decreased albumin (liver failure) Hypothyroidism Meig's syndrome **Exudate: unilateral, protein \>30g/L** **IIICT** Infection: pneumonia, TB Inflammation: Rheumatoid arthritis, SLE Infarction: PE Ca: primary or secondary Trauma

Answer 16

Differentiate a transudate and exudate if 25-30g/L Take a pleural tap Effusion:serum **protein ratio \>0.5** Effusion:serum **LDH ratio \>0.6** **Effusion LDH is 0.6x ULN**

Answer 17

**Identify cause:** Fever Sputum Smoking Weight loss Haemoptysis Previous MI Orthopnoea PND Hepatitis

Answer 18

**Bloods** FBC: anaemia, U+E: creatinine raised, LFTs: hypoa;buminaenia, TFT: raised TSH, ESR raised in CTD, Ca raised in cancer **CXR:** homogenous opacification wih meniscus, signs of cause e.g. mets **USS:** guide pleuocentesis **Volumetric CT** **Diagnostic pleurocentesis**: Send to chemistry for protein, LDH, pH, glucose, amylase Send for micro: MC+S, auramine stain, TB culture Send for cytology Send for immunology: RF, ANA, complement Pleural biopsy

Answer 19

Treat underlying cause May use drain / repeated aspiration **Drain \<2L per day!** Pleurodesis if recurrent malignant effusion Persistent effusions may require surgery

Answer 20

**Inspection** Cachexia Hoarse voice or stridor **Hands** Clubbing Hypertrophic pulmonary osteoarthropathy (HPOA) Tar staining Claw hand and wasting of interossei **Face** Anaemia Horner's Plethora **Neck** LNs Dilated veins **Chest** Thoracotomy scar Radiotherapy square birn + tattoo Acanthosis nigrans **Collapse** Tracheal deviation towards collapse Decreased expansion Dull percussion note Absent air entry Increased VR **Effusion** Tracheal deviation away from effusion Reduced expansion Stony dull percussion Reduced air enrty Reduced VR

Answer 21

HPOA Present in up to 10% lung cancers More common in non-small cell cancer

Answer 22

**Superior vena cava obstruction** Plethroic Oedematous face Oedematous upper limbs Dilated neck and chest veins Stridor **Recurrent laryngeal nerve palsy** Hoarse voice Bovine cough **Pancoast tumour** Horner's Claw hand with wasting of interossei - **compression of ulnar nerve** **Dermatomyositis**

Answer 23

**Inspection** Clubbing Cachexia **Scars** Lateral throacotomy Clamshell: double lung transplant Chest drains VATS Chest wall asymmetry or deformity **Pneumonectomy** Tracheal and apex shift to abnormal side Decreased expansion Dull percussion NO breath sounds **Lobectomy** Tracheal shift (mainly upper lobectomy) Focal signs Reduced expansion Dull percussion Reduced breath sounds

Answer 24

**Lobectomy** **Pneumonectomy** **Normal lung** Abscess Empyema Biopsy Wedge **Transplant**

Answer 25

**Non-disseminated bronchial carcinoma (90%)** Other bronchiectasis COPD: lung reduction TB: historic, upper lobe

Answer 26

**Mortality** Lobectomy: **7%** Pneumonectomy: **12%** **Increased risk:** ASA grade Age \>70 Poor respiratory reserve: FEVA:FVC ratio \<55%

Answer 27

ADH --\> SIADH ---\> hyponatraemia Cushing's syndrome (ACTH) Carcinoid syndrome (Serotonin) Hypercalcaemia (PTHrP) SCC

Answer 28

_Non-small cell_ **Squamous cell carcinoma: 35%** Central, smokers **Adenocarcinoma: 25%** Peripheral, Non-smoker **Large-cell: 10%** **_Small-cell lung cancer: 20%_** Central, Smokers

Answer 29

Highly related to smoking Central PTHrP --\> hypercalcaemia Non-Small Cell

Answer 30

Female non-smokers Peripheral 80% present with extra-thoracic mets Non-Small Cell

Answer 31

Highly related to smoking Central 80% present with advanced disease Ectopic hormone secretion

Answer 32

**Endocrine** ADH --\> SIADH ACTH --\> Cushing's Serotonin --\> Serotonin syndrome PTHrP --\> primary hyperparathyroidism (Squamous cell) **Rheumatological** Dermatomyositis Polymyositis **Neuro** Cerebellar degeneration Peripheral neuropathy **Derm** Acanthosis nigricans Trousseau syndrome: thrombophlebitis migrans

Answer 33

**Local** SVCO Horner's Phrenic nerve palsy AF Recurrent laryngeal nerve palsy **Paraneoplastic** SIADH Cushing's Hypercalcaemia **Metastatic** Pathological # Hepatic failure Neurological Addison's

Answer 34

**Bloods** FBL anaemia, increased WCC (if consolidation) U+Es: Hyponatraemia (SIADH) LFTS: deranged due to liver mets Bone profile: Increased calcium (PTHrP Sqaumous cell) **Imaging** CXR Contrast enahnced volumetric CT of thorax **Cytology** Induced sputum Pleural fluid (USS-guided pleurocentesis) **Histology** Percutaneous FNA Endoscopic transbronchial USS guided **Staging** CT PET Thoracoscopy **Pulmonary function tests** Assess fitness for surgery Pneumonectomy contraindicated if FEV1 \<1.2L

Answer 35

**General Mx** MDT Stop smoking Optimise nutrtion and CV function **Non Small Cell** Surgery first line if Curative radiotherapy Chemo: platinum based + biologics 50% 5ys with no spread, 10% 5ys with spread **Small Cell** Chemo Radio therapy Pallative 3 months untreated survival, 1-1.5 yrs median treated **Pallative Care** Analgesia: opiates for pain and cough Radiotherapy SVCO: dexamethasone + radiotherapy +/- stent Persistent effusion: Pleurodesis

Answer 36

**Inspection** Febrile Looks unwell Tachypenoeic Tachycardia Cough Rusty sputum **Chest: Consolidation** Decreased expansion Dull percussion BRonchial breathing Decreased air entry Focal coarse crackles Pleural rub Increased vocal resonance Para-pneumonic effusion Erthyema multiforme = mycoplasma pneumonia **DDx** Collapse Effusion

Answer 37

**Bedside** Sputum MC+S Urine: Pneumococcal antigen Hb (cold agglutins--\> haemolysis) **Bloods** FBC, U+Es, CRP, LFT, Culture Paired sera: mycoplasma, chlamydia, Legionella ABG **CXR** Conslidation with air bronchogram Effusion Cavities: staph aureus, klebsiella **Pleurocentesis** Bronchoalveolar lavage

Answer 38

**CURB-65 Score** **Specific:** Antibiotics and Analgesia **Supprortive** Oxygen Fluids Chest physio **Complications** Septic shock --\> MOF Para-pneumonic effusion Empyema Resp failure Abscess **Follow-Up** **CXR at 6 weeks** to rule out cancer **Smoking cessation** **Pneumovax (23 valent)** \>65 years At-risk Revaccinate every 6 years

Answer 39

**Bronchopneumonia:** Patchy consolidation of different lobes **Lobar pneumonia:** Fibrosuppuratve consolidation of a single lobe Congestion --\> red hepatization --\> grey hepatization --\> resolution

Answer 40

**Streptococcus Pneumoniae: 50%** Mycoplasma: 6% Haemophilus (increased in COPD) Chlamydia pneumonia Viruses: 15%

Answer 41

**Pseudomonas** MRSA Gram negative enterobacteria (Klebsiella)

Answer 42

**Amoxicillin** AND **Clarithromycin** Cover atypicals

Answer 43

**Co-amoxiclav** OR **Tazocin** +/- **Vancomycin**

Answer 44

Increased risk: **stroke,** bulbar palsy, decreased GCS, GORD, Achalasia Posterior segment of Right lower lobe **Co-amoxiclav**

Answer 45

**Amphotericin**

Answer 46

**Ganciclovir**

Answer 47

**Fever, Headaches, Myalgia,** **Mycoplasma** **Chlamydia** **Legionella**

Answer 48

**C**onfusion: AMT 8 or less **U**rea: \>7 **R**esp: \>30/min **B**lood pressure: systol \<90, diastol \<60 mmHg Age: **\> 65** 0-1 --\> manage in community unless significant comorbities 2 = hospital 3 or more --\> consider ITU

Answer 49

**Sepsis and MOF Para-pneumonic effusion / epyema** **Abscess:** staph aureus, klebsiella, anaerobes **Respiratory failure**

Answer 50

**Inspection** Asymmetry: absent ribs Scars: **thoracoplasty** (removal of several ribs to collpase upper portion of lung) ScarL **supraclavicular fossa** - phrenic nerve crush **Chest** **Tracheal deviation towards apical fibrosis** Decreased expansion Dull to percussion +/- bronchial breathing Reduced air entry Crackles Increased vocal resonance

Answer 51

Lower PaO2 would inhibit TB Healed cavities seemed to be closed - hence the logic of closing cavities would heal them **Induction of apical collapse** **Techniques** Pliombage: insetion of polystyrene balls into thoracic cavity Phrenic nerve cursh --\> diapohragm paralysis Thoacoplasty (rib removal and collapse) Apical lobectomy

Answer 52

_Initial Phase 2 months: **RIPE**_ **Rifampicin (6 months)** **Isoniazid (6 months)** AND Pyridoxine (Vitamin B6) **Pyrazinamide** * converted to pyrazinoic acid by mycobacterial pyrazinamidase * lowers environmental pH * works best within macrophages **Ethambutol** * blocks arabinosyltransferase * inhibits carbohydrate polymerization of mycobacterial cell wall * resistance arises from increased production of arabinosyltransferase by bacteria

Answer 53

**Rifampicin:** Hepatitis **Orange/Red secretions:** urine and tears Enzyme induction **Isoniazid** Peripheral sensory neuropathy (give B6) Hepatitis **Pyrazinamide** Hepatitis Arthralgia Breaks down into uric acid and causes gout (CI in gout and prophyrias) **Ethambutol** Optic neuropathy --\> Red-green colour blind

Answer 54

**Primary TB** Naive TB infection Multiples at pleural surface --\> **Ghon focus** Macrophages take TB to LNs --\> **Ghon complex** Mostly asymptomatic, may have fever and essusion Fibrosis of Ghon complex into calcified nodule (**Ranke** complex) occurs in 95% ~ immunocompetent people **Rarely, primary progressive TB in immunocompromised** Resembles acute pneumonia Mild and lower zone consolidation Effusions, Hilar LNs Spead to extra-pulmonary and miliary TB **Latent TB** Infected but no clinical of x-ray signs of **active** TB due ot host immunity Non-infectious Weakended host immunity --\> reactivation **Secondary TB** Usually reactivation of latent TB May be due to reinfection Develops in upper lobes Hypersenisitivity: tissue destruction ---\> caseating granulomas

Answer 55

**Latent TB** Tubercullin skin test If positive ---\> IGRA **Active TB** CXR If suggestive --\> 3 spuutm samples --\> MC+S with **Ziehl-Neelsen stain** and **Lowenstein-Jensen media** culture **PCR** Can detect Rifampicin resistance Can be used if unable to grow anything

Answer 56

Intradermal injection of purified protein derivative Induration measured at 48 hours **False positive** = BCG, other mycobacteria, prev exposure **False negative** = HIV, sarcoid, lymphoma

Answer 57

IGRA Patient's lymphocytes incubated with mycobacterium tuberculosis specific antigens Cuases IFN-y release if previous exposure **Will not be positive is BCG only as BCG uses M.bovis**