Respiratory Flashcards
what is alpha 1 antitrypsin deficiency ?
an autosomal recessive/co-dominant disease caused by lack of protease inhibitor usually produced by the lungs
patients usually have the PiZZ genotype
how is secondary pneumothorax managed?
if patient is >50 years old and air rim >2cm = chest drain
if air rim 1-2cm then aspirate, and if this fails then chest drain
if air rim < 1 cm then oxygen and 24 hour monitoring in hospital
what are the symptoms/signs of Cor Pulmonale?
peripheral oedema, raised JVP, loud P2, parasternal heave (RV), dyspnoea, fatigue, tachycardia, cyanosis, hepatosplenomegaly
what is Kartageners syndrome?
also known as primary ciliary diskenisia
dyenin arm defect results in imotile cilia
what are the paraneoplastic features of lung adenocarcinoma??
HPOA
gynaecomastia
how is latent Tb treated?
3 month Isoniazid and rifampacin
or
6 month isoniazid
what are the features of ABPA?
bronchiectasis (permanently enlarged, mucus filled airways)
bronchoconstriction - cough, wheeze, dyspnoea
presentation of peripheral tingling, prominent dizziness and light headedness is associated with what?
dysfunctional breathing
e.g. hyperventilation
which lung fibrosis mainly affects the lower zones?
idiopathic pulmonary fibrosis
asbestosis
drugs - methotrexate. amiodarone, bleomycin
most connective tissue disorders ( Except ankylosing spondylitis)
how is Cor pulmonale managed?
loop diuretic (furosemide) long term oxygen
how do we manage COPD?
1) smoking cessation etc
2) SAMA (e.g. ipratropium) or SABA (e.g. sabutamol, fenoterol)
3) if FEV1 <50% then give a LAMA (tiotropium) or a LABA (salmeterol) with ICS (combo inhaler)
4) if FEV1 >50% then give a LAMA or a LABA
5) if problems continue - add medication so that the patient is prescribed a LAMA, LABA and ICS
oral theophyline can be considered if none of the above work
mucolytics may be offered in chronic, sputum production and cough
what are causes for respiratory alkalosis?
hyperventilation - anxiety pulmonary embolism altitude pregnancy CNS disorders - stroke, encephalitis, subarachnoid haemorrhage
what is ABPA?
allergic bronchopulmonary aspergillosis
results from an allergy of aspergillus spores
what are the features of a life-threatening asthma attack?
PEFR <35% Oxygen sats <92% silent chest, cyanosed, weak resp effort bradycardia, hypotension, dysrhythmia, exhaustion, confusion, coma
when do you make a 2 week referral for lung cancer?
- cxr findings which suggest lung cancer
2. over 40 with unexplained haemoptysis
what is type 2 resp failure?
there is hypoxia as well as hypercapnia. this leads to acidosis. there is attempts at metabolic compensation with raised bicarbonate
where is emphysema more prominent in COPD?
upper lobes
how is emphysema defined histologically?
increased air spaces distal to the terminal bronchioles with destruction of the alveolar walls
how many lung cancer cases are small cell LC?
15%
how do asthma patients present?
intermittent wheeze, dyspnoea, cough, sputum
often nocturnal
brought on by precipitants e.g. cold weather, exercise, emotion, infection, allergens, NSAIDs, beta blockers
diurnal variation - marked decrease in the morning
disturbed sleep
acid reflux
other atopic traits - eczema, hayfever
what are the features of klebsiella pneumonia?
more common in alcoholics and diabetics sputum like red current jelly common with aspiration affects upper lobes commonly causes lung abscess and empyema
what factors may improve survival in COPD patients?
Smoking cessation - most important
long term oxygen therapy
lung volume reduction surgery
when is long term oxygen therapy indicated?
PaO2 <7.3 on air - (proved by 2 arterial blood gases)
PaO2 < 8 on air with evidence of Cor Pulmonale (peripheral oedema, pulmonary hypertension), secondary polycythaemia, nocturnal hypoxaemia
what are the features of A1AD?
panacinar emphysema - most marked in lower lung lobes
liver: cirrhosis and hepatocellular carcinoma, cholestasis in children
what are the features of katargeners syndrome?
subfertility
dextrocardia or complete situs inversus
bronchiectasis
recurrent sinusitis
what is Lambert Eaton syndrome?
a rare autoimmune disease, in which antibodies are formed against presynaptic calcium channels of neuromuscular junctions
it causes weakness to muscles, mainly to lower limb muscles.
weakness subsides with exertion and
when should a chest tube be placed to drain pleural fluid?
- if the pleural fluid is cloudy/turbid or purulent
2. if the pleural fluid has a pH <7.2 in a patient with a suspected infection
what is the pathophysiology of emphysema?
inflammatory response leads to elastin breakdown and so loss of integrity of the alveoli
what are the paraneoplastic features of small cell lung cancer?
ADH secretion - causing hyponatraemia
ACTH secretion - causing hyperaldosteronism
Lambert- eaton syndrome (autoimmune muscle condition - causing weakness)
how is obstructive sleep apnoea treated?
weight loss
CPAP
intra oral devices if CPAP is not tolerated
what are causes for raised TLCO?
asthma male, hyperkinetic state exercise polycythaemia left to right cardiac shunts pulmonary haemorrhage (goodpastures, wegners)
what are Anti-Yo antibodies?
associated with breast cancer
can produce nystagmus by attacking neurones
how is moderate risk pneumonia treated?
dual antibiotics = amoxicillin and a macrolide
7-10 day course
how does HPOA present?
a paraneoplastic feature of lung cancer
it involves excess bone deposition = causing pain in wrist and ankle
what are causes for a transudate pleural effusion?
heart failure
hypoalbuminaemia
hypothyroidism
meigs syndrome
what is COPD?
a progressive disorder characterised by airway obstruction with little or no reversibility
it includes emphysema and chronic bronchitis
what are causes of ARDS?
acute pancreatitis sepsis trauma direct lung injury long bone fracture/break (fat emboli) head injury
what advice should you give a patient with pneumonia in regards to feeling better?
week 1 - fever ends week 4 - sputum and chest pain finish week 6 - cough and SOB finish month 3 - almost all symptoms resolved,except for tiredness month 6 - back to normal
what are findings on a COPD CXR?
hyperinflation, flat hemidiaphragms, bullae,large central pulmonary arteries, decreased peripheral markings
what respiratory problems are seen in patients with rheumatoid arthritis?
pulmonary fibrosis pleural effusion infection drug interaction = methotrexate pneumonitis Caplans syndrome pleurisy pulmonary nodules bronchiolitis obliterans
what are the diagnostic criteria for COPD?
FEV1/FVC <70% with symptoms of COPD
what is the relationship between mesothelioma and asbestos exposure?
90% of mesothelioma patients had previous exposure to asbestos, but only 20% have pulmonary asbestosis
what is atelectasis?
a complication post surgery where basal alveoli collpase due to secretions blocking the bronchial airways.
how are COPD exacerbations treated?
Oxygen therapy to maintain sats at 92% nebulised SABA high dose corticosteroids antibiotics if purulent reassess in 1 hour - if continued respiratory acidosis then consider: IV bronchodilator ICU opinion Ventilation
how is idiopathic pulmonary fibrosis managed?
poor prognosis (3/4 year)
pulmonary rehabilitation
oxygen therapy and lung transplant
antifibrotic medication may help in some patients e.g. pirfenidone
what are contraindications for surgery for NSC lung cancer surgery?
malignant pleural effusion vocal cord paralysis superior vena cava obstruction grade 3b or 4 disease general health FEV1 < 1.5 L tumour near hilum
when should antibiotics be prescribed?
IF the patient is... systemically unwell at risk of complications pre-disposing mortalities >65 with 3 symptoms or >80 with 2 symptoms hospitalisation within past year diabetes 1 or 2 use of oral glucocorticoids history of CHF
what are causes for a exudate pleural effusion?
infection - pneumonia, Tb connective tissue disease pulmonary embolism Dresslers syndrome neoplasia pancreatitis
what is the pathophysiology of COPD?
smoking leads to inflammation
inflammatory response caused goblet cell hyperplasia and increased activity
bronchoconstriction - airway narrowing
alveoli destruction
what are the hallmarks of COPD?
sputum production
chronic cough
Breathlessness
how is miliary Tb spread?
through the pulmonary venous system
what are features of pulmonary oedema on a CXR?
interstitial oedema bat wings appearance kerly B lines pleural effusion cariomegaly if cardiogenic source upper lobe diversion of blood
how is active Tb treated?
rifampicin or isoniazid - either can be used, 2 month intense and then 4 months continuation
or
pyrazinamide or ethambutal - can either be used 2 months intensively
an asthma patient presents with 5 days of coughing and wheezing, what do you do?
5 day course of prednisolone for all asthma exacerbations
what does poorly controlled asthma look like?
more variation between trough and peak levels = poor control
taking time off work
hospital admittance
night symptoms
tell me about varenicline?
a nicotine receptor agonist
should be started a week before the desired ‘stop smoking’ day and continued for 12 weeks
common side effect = nausea. others include insomnia, headaches, abnormal dreams
contraindicated in pregnancy and breast feeding
caution in self harm and depression
when should invasive ventilation be considered?
if pH <7.25
what is the classic CXR finding in pneumonia?
consolidation
what investigations should you do if COPD exacerbation is suspected?
CXR, ECG, ABGs, FBC, U&Es, CRP,
sputum culture if purulent
how is suspected asthma diagnosed?
fractional exhaled nitric oxide (FENO) test - >40 is consider positive in adults and >35 in children
spirometry/bronchodilator reversibility test FEV1/FVC < 70% and an increase in 12% of FEV1 and by 200ml
how do we classify COPD (GOLD criteria)
1) MILD >80% predicted
2) MODERATE 50% - 80% predicted
3) SEVERE 30-50% predicted
4) VERY SEVERE <30% predicted
how is an acute asthma attack managed?
oxygen high flow
salbutamol nebulised (and ipratropium if life-threatening)
IV hydrocortisone or PO prednislone
repeat salbutamol if PEF remains <75%
consider magnesium sulphate if life threatening and no good response
if not improving refer to ICU.
if improving, continue rounds of salbutamol and give prednisolone for 5-7days
what is a transudate and exudate?
transudate is fluid which leaves the capillaries because of either decreased protein or increased hydrostatic pressure. it contains little protein
exudate is fluid which leaks through inflamed capillaries, with lots of protein
what are the symptoms of a mesothelioma?
cancer of the pleura
symptoms = CP, dyspnoea, recurrent pleural effusions, finger clubbing, signs of metastasis, weight loss
what vaccinations should we offer COPD patients?
once off pneumococcal vaccine
annual influenza vaccine
how is a pleural aspiration performed?
under ultrasound guidance to avoid complications
21G needle and 50ml syringe should be used
fluid should be sent off for pH, lactam dehydrogenase, microbiology, protein, cytology
how can Tb present?
it can affect any organ in the body
general systemic symptoms
lung infection = haemoptysis, pleurisy, aspergilloma, cough, pleural effusion
tuberculous lymphadenitis - swollen carvical or supraclavicular nodes
Miliary Tb - foci of granulomatous tissue throughout lung parenchyma. dissemination can be throughout the body - to meninges, CNS. foci of infection in brain and spinal cord - can lead to symptoms of meningitis, headache, seizures,, confusion, focal neurological deficits (granulomas formed)
Genitourinary and cardiac symptoms
skin - lupus vulgaris
when are steroids indicated in sarcoidosis treatment?
parenchymal lung disease,
eye, heart or neuro involvement
hypercalcaemia
what are oxygen recommendations for patients who are critically ill?
15L/min via a reservoir mask
what are the features of idiopathic pulmonary fibrosis?
progressive exertional dyspnoea
clubbing
dry cough
bibasal crackles on auscultation
what is the main fungal cause of pneumonia in immunosuppressed ?
pneumocystis jiroveci
what are causes of white shadowing in the lungs on a CXR?
consolidation pleural effusion pneumonectomy fluid e.g. pulmonary oedema lesions e.g. tumour collapse
what are the characteristics of Asthma?
airflow limitation
airway hyper responsiveness
bronchial inflammation
bronchial muscle contraction, mucosal inflammation (mast cells and basophils) and excess mucus production lead to intermittent, reversible airway restriction
tell me about bupropion …
a NE and Dopamine reuptake inhibitor and nicotinic antagonist
should be started 2 weeks before target end date
contraindicated in pregnancy, breast feeding and epilepsy
relative CI in eating disorders
small risk of seizures
what are the complications of COPD?
pneumothorax from ruptured bullae
acute exacerbations with/without infections
polycythaemia (hypoxia leads to increased RBC production)
cor pulmonale
respiratory failure
lung carcinoma
what investigations are done for pneumonia?
CXR
for moderate/high risk = blood and sputum cultures and legionella +pneumococcal urinary antigens
CRP monitoring
what are the features of granulomatosis with polyangitis?
upper resp: sinusitis, nasal crust , epistaxis
lower resp: dyspnoea, haemoptysis
kidney: v. rapidly developing glomerulonephritis
saddly-shaped nose deformity
also: eye involvement, vasculitic rash, cranial nerve lesions
what are the indications for non-invasive ventilation?
respiratory acidosis (7.25-7.35) in COPD patients weaning off intubation respiratory failure secondary to chest wall deformity, neuromuscular disease or sleep apnoea cardiogenic pulmonary oedema unresponsive to CPAP
what medical therapy should a patient receive if admitted with a COPD exacerbation?
oxygen therapy
IV bronchodilators
steroids
antibiotics if needed
if not responding: IV theophylline, non invasive venitlation (BIPAP)
how is asthma managed? stepwise approach
1) SABA
2) SABA + Low dose ICS
3) SABA + ICS + Leukotriene receptor antagonist LTRA
4) SABA + ICS + LABA +/- LTRA (depending on patients response)
5) SABA + low dose MART (combined LABA/ICS inhaler) +/- LTRA
MART=maintenance and reliever therapy
6) SABA + medium dose MART+/- LTRA
7) SABA +/- LTRA +high dose ICS
trial LAMA or theophylline or seek advice
what is sarcoidosis?
a multisystem disease with unknown aetiology that is characterised by non-caseating granulomas
more common in young adults and people of african descent
what are the investigations for wegeners granulomatosis?
CXR - showing cavitating lesions
cANC positive (90%) pANCA positive (15%)
renal biopsy: epithelial crescents in bowmans capsule
what are types of Non Small Cell Lung Cancer?
squamous adenocarcinoma large cell bronchiol alveolar cell - loads of sputum, not related to smoking
what pathology causes loss of the left heart border on CXR?
left lingula pneumonia
what are the features of sarcoidosis?
acute - erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia
hypercalcaemia = macrophages inside the granulomas cause an increased conversion of Vit D to its active form
insidious = dyspnoea, dry cough, malaise, weight loss
skin - lupus pernio
can cause facial palsies, parotid enlargement and ocular problems
how is life threatening asthma attack managed?
magnesium sulphate IV
if not helping
consider IV salbutamol
what investigations should be performed in suspected COPD?
spirometry: showing an obstructive picture. FEV1/FVC - <70%
BMI
CXR - looking for hyperinflation, flat hemidiaphragm, bullae
FBC: exclude secondary polycythaemia
how do we assess severity in patients with pneumonia?
with CURB 65
C = Confusion U = Urea >7 R = Resp Rate = 30 B = BP = <90/60 65 =Age >65
what is the lifetime risk of reaction of latent Tb?
5-10%
how do patients with chronic bronchitis-dominant COPD present?
“blue bloaters”
these patients have decreased alveolar ventilation. they are hypoxic and hence cyanosed.
the obstruction leads to increasing residual lung volume - causing bloating
there is a large V/Q mismatch
these patients are at risk of cor pulmonale
they are hypercapnic, and rely on hypoxic drive to maintain respiratory effort
what is the prognosis of cor pulmonale?
poor
50% die within 50 years
how is chronic bronchitis defined clinically?
cough and sputum production on most days in 3 months of 2 successive years
what are the B symptoms of cancer?
fever
night sweats
fatigue
how is care escalated for acute severe asthma?
oxygen nebulised salbutamol nebulised ipratropium hydrocortisone IV or oral prednisolone IV magnesium sulphate IV salbutamol/aminophylline
how are pneumonia patients stratified and then treated?
by CURB 65 score
score 0 = home care - low risk
score 2+ = hospital based care -intermediate risk
score 3+ intensive care assessment - high risk
what is meig’s syndrome?
a triad of benign ovarian tumour, ascites and pleural effusions
what are the signs of a severe asthma attack>
unable to complete sentences
pulse >110
RR > 25
PEFR 33-50% predicted
what are investigations for suspected lung cancer?
CXR CT Bronchoscopy - biopsy the tumour PET Scan - helps to grade the tumour and decide eligibility for treatments CT TAP recommended
what are the centor criteria and what are they used for?
if 3 of 4 are present, it is likely the infection is due to Group A beta haemolytic streptococcus and so antibiotics should be prescribed
1) tonsillar exudate
2) tender anterior cervical lymphadenopathy or lymphadenitis
3) no cough
4) history of fever
what measurement is associated with poor prognosis in community acquired pneumonia?
raised urea levels
when should a COPD diagnosis be considered?
in a patient over 35 with a smoking history, who have symptoms such as exertional breathing, cough, sputum production
what is ARDS?
adult respiratory distress syndrome
defined as pulmonary infiltrates with severe hypoxia without evidence of cardiogenic pulmonary oedema (CVP<18mmHg)
multi organ damage
rising ventilatory pressure
in which situations should oxygen therapy be avoided if there are no signs of hypoxia?
anxiety related hyperventilation
stroke
MI or ACS
Obstetric emergencies
what is churg-strauss syndrome ?
an ANCA assocaited, medium vessel vasculitis
what are the symptoms of COPD?
dyspnoea, wheezing, chronic cough, sputum, winter exacerbations
what is defined as a primary pneumothorax?
a pneumothorax in a patient without any underlying lung disease
what are clinical features of hypercapnia?
dilated pupils, hand flap, bounding pulse, confusion, coma, myoclonus
what are causes of bronchiectasis?
cystic fibrosis, post-infection -Tb, pneumonia immune deficiency bronchial obstruction yellow nails syndrome ciliary dyskinetic syndromes: Kartegenars, youngs Allergic bronchopulmonary aspergillosis
how do we treat severe pneumonia with sepsis?
broad spectrum piperacillin-tazerbactum (pipTaz) and clarithromycin (covers atypical causes)
what are causes for a lower TLCO?
pulmonary embolism pneumonia pulmonary fibrosis emphysema oedaema anaemia low cardiac output
what is the main therapeutic benefit of using inhaled corticosteroids in COPD?
it reduces the frequency of exacerbations
how is latent Tb diagnosed?
1) Mantoux test = tuberculin skin test
- purified protein derivativ tuberculin is injected interdermally, if a hard lump 5-15mm arises = +ve test
2) Interferon Gamma release assays = to detect gamma rays released by Tb cells
which side of the lung will aspiration pneumonia commonly present?
right side - right inferior bronchi
this is the easiest route for foreign bodies to fall
what investigations should be performed if Cor pulmonale suspected?
FBC = raised Hb and haematocrit = polycythaemia CXR = Right sided hypertrophy, prominent pulmonary arteries ECG = sinus tachy, P pulmonale (peaked P waves in lead 2), right axis deviation ABG = hypoxia, hypercapnia,
what is the best investigation for suspected occupational asthma?
serial peak flow readings at home and in work
specialist referrals should be made for occupational asthma
what are clinical signs of pneumonia?
signs of systemic inflammation = tachycardia, fever
auscultation = bronchial breathing, reduced breath sounds
reduced oxygen saturation
what are signs of asthma?
tachypnoea, audible expiratory wheeze, hyperinflation, decreased air entry, hyperresonant percussion notes,
what are Anti - Hu antibodies?
antibodies which are associated with small cell lung cancer. they attack neurones and can present as dizziness and vertigo.
how is a primary pneumothorax managed?
- if the air rim is <2cm and patient isn’t breathless - consider discharge
- otherwise if >2 cm or symptoms, perform aspiration
- if aspiration fails, insert an intercostal chest drain
patients should be advised to stop smoking
what is the incidence of pneumothorax?
10% in smoking men
0.1% in non smoking men
how is high risk pneumonia treated?
dual antibiotic therapy
7-10 course
beta lactamase stable penicillin (e.g. co-amoxiclav, pipTaz, ceftriaxone ) with a macrolide
what is the most common bacterial cause of COPD exacerbation?
haemophilius influenza
what are the differentials for an acute asthma attack?
COPD exacerbation pulmonary embolism anaphylaxis pneumonia pulmonary oedema upper resp tract infection
must you inform anyone about a patient with Tb?
yes- all cases must be reported to a local public health protection team
what are risk factors for OSA?
obesity
macroglossia e.g acromegaly, hypothyroidism
large tonsils
marfans
how do patients with emphysema-dominant COPD present?
“pink puffers”
there is alveolar ventilation with almost normal PaO2 (not cyanosed) and normal or low PaCO2 (hyperventilation).
destruction of alveoli and capillary beds means there is equal decrease in perfusion and ventilation and so not much V/Q mismatch, if any.
the patient hyperventilates to compensate - giving normal ABGs
at risk of type 1 resp failure
how do you differentiate between obstructive and restrictive pulmonary disease?
in obstructive, there will be a big decrease in FEV1 - because it struggles to push lots of air quickly out of the lungs, however FVC is normal or slightly lower.
this means the FEV1/FVC ratio will be low < 0.7
in restrictive disease, FEV1 and FVC are lowered equally, so the ratio remains normal or even raised >0.75
what are features of churg-strauss?
asthma blood eosinophilia pANCA positive mononeuritis multiplex paranasal sinusitis
what are typical bacterial causes of community acquired pneumonia?
gram positive bacteria are most common e.g. streptococcus pneumoniae other major causes: Haemophilius influenza (gram -ve) mycoplasma pneumoniae (atypical)
what treatment should be offered for smoking cessation?
Nicotine replacement therapy
bupropion
varenicline
what is granulomatosis with polyangitis?
formally known as Wegener’s granulomatosis
it is an autoimmune necrotizing granulomous vasculitis that affect upper and lower respiratory tracts as well as the kidneys,
what are the complications of pneumonia?
pleural effusion - build up of exudate in the pleural space (50% cases)
empyema - build up of pus in the pleural space. signs include swinging fevers and cont. raised inflammatory markers
sepsis
lung abscess
respiratory failure
pericarditis, myocarditis …
what are complications of asbestos exposure?
pleural plaques (most common) pleural thickening mesothelioma lung cancer asbestosis
what are typical causes of hospital acquired pneumoniae?
Gram negative enterobacteria - E.coli, klebsiella Staphylococcus Aures (Gram positive coccus)
how does cor pulmonale happen in COPD?
hypoxia causes pulmonary capillaries to constrict. this leads to a build up of pressure in the pulmonary arteries which then increases the pressure in the right side of the heart. this can then cause failure over time
what are risk factors for aspiration pneumonia?
prolonged hospital stay decreased consciousness poor mucociliary clearance poor dental hygiene recent intubation poor swallowing
how is low risk pneumonia treated??
1st line = amoxicillin 5 day course
2nd line = macrolide or tetracycline
which medication is best in treating aspirin-induced asthma?
montelukast
a leukotriene receptor antagonist
(aspirin leads to excess leukotriene production - which is >100 times more potent bronchoconstrictor than histamine)
when do you make a 2 week referral for suspected laryngeal cancer?
for patients >45 years who
- have persistent hoarsness
- unexplained lump in the neck
how does aspergilloma present??
past history of Tb
rounded opacity on CXR surrounded by rim of air
haemoptysis
what is the pathophysiology of tuberculosis?
phase 1 = active disease. reactivation or primary disease. immune system inadequate to control it
phase 2 = latent Tb. persistent immune system containment. granuloma formation prevents the bacteria spreading. they will have positive skin and blood test but are asymptomatic.
what is the correct format for handing over to the ambulance?
SBAR situation background assessment recommendations
what are causes for bilateral hilar lymphadenopathy?
sarcoidosis and tuberculosis are most common
also lymphomas,
what are the most common causes of COPD infective exacerbation ?
H influenza
streptococcus pneumonia
pseudomonus aures
moraxella
what are the clinical signs of COPD?
tachypnoea, tar staining, accessory muscle use, hyperinflation, cyanosis, resonant/hyper-resonant percussion, quiet breath sounds over bullae, decreased cricosteronal distance, signs of cor pulmonale, wheeze, decreased lateral expansion
what should the oxygen sats target be in COPD patients?
if their CO2 is normal = 94-98%
if they are hypercapnic = 88-92% (using a 28% venturi mask at 4L/min)
how does mitral stenosis present?
mid diastolic murmur
atrial fibrillation
haemoptysis
cheek - malar flush
what is type 1 respiratory failure?
low PaO2, all other levels normal
just hypoxia
how is active Tb diagnosed?
sputum smear, sputum culture,
CXR= looking for opacities/granulomas in upper lobe (common), cavitations, miliary disease, effusion, lymphadenopathy, calcification
Nucleic acid amplification test- direct testing of Tb DNA/RNA in patients sputum
difficulty walking and muscle tenderness in a patient with suspected lung cancer, raises suspicion of what?
lambert eaton syndrome
secondary to small cell lung cancer
what is the safe triangle for chest drain insertion?
5th intercostal space
mid-axillary line
what are spirometry findings in COPD?
FEV1/FVC <0.7
FEV1 <80% predicted
increased TLC and RV
decreased TLCO
when is surgery considered in small cell lung cancer?
in very early stage disease e.g. T1 N0 M0
what is bronchiectasis?
permanent dilation of the airways secondary to chronic inflammation or infection
how should an Upper resp tract infection be treated?
paracetamol and review in 3-4 days
avoid prescribing antibiotics
how is ABPA managed?
steroids and anti fungals
how do you clinically differentiate between a transudate and an exudate?
exudate: protein levels >30g/L
transudate: <30g/L
if the protein level is between 25-30g/L we can apply Light’s criteria. an exudate is likely if the one of the following criteria apply:
1. pleural protein divided by serum protein >0.5
2. pleural LDH divided by serum LDH >0.6
3. pleural fluid LDH is >2/3 the upper limit of serum LDH
what are the paraneoplastic features of squamous cell lung cancer?
ectopic TSH secretion
Ectopic PTH secretion - causing hypercalcaemia
clubbing
HPOA -hypertrophic pulmonary osteroarthropathy
how is a tension pneumothorax produced?
trauma penetrates the lung creating a parenchymal one-way flap. air enters the lung in one-direction and pressure rises. this pushes the trachea and mediastinum in the other direction
it is treated with needle decompression and chest tube drain
what is the pathophysiology of chronic bronchitis?
inflammation leads to ciliary dysfunction and increase in number and activity of goblet cells. this leads to hyper-secretion and chronic cough.
the excess mucus together with inflammatory swelling of the airway leads to decreased airflow
what are important questions for an asthma review?
is your sleep disturbed by asthma
are your usual daily activities disturbed by asthma
what are the phases of Churg-strauss?
phase 1 = allergy stage. asthma and rhinitis. inflammation can lead to nasal polyps
Phase 2 = eosinophilia
phase 3 = vasculitis. leading to organ damage
first investigation if SIADH is suspected?
urinary sodium
if >40mmol is points towards SIADH
in SIADH, urine osmolarity>serum osmolarity
what are common causes of lobar lung collapse?
asthma due to mucus plugging
foreign body
lung cancer
what are typical blood test results in ABPA?
eosinophilia
raised IgE
aspergillus specific IgE
CXR changes - mucus plugging (bronchoeles) - finger like lesions - common feature
how is a diagnosis of idiopathic pulmonary fibrosis made?
spirometry: restrictive pattern = FEV1 -normal/decreased, FVC-decreased, FEV1/FVC raised
impaired gas exchanged = reduced TLCO
Imaging, high resolution CT = small, irregular, peripheral opacities - initially ground glass and then progressing to honey comb. more at the bases
what are causes of widening of the mediastinum on CXR?
lymphoma teratoma retrosternal goitre tumours of the thymus vascular problems: thoracic aorta aneurysm
what do we offer a patient under 60 who presents with pneumonia?
HIV test
a patients blood grows acid fast bacilli and histology of a lung lesion shows epitheloid histocytes. what is the pathology?
Tuberculosis
epitheloid histocytes are seen in Tb granulomas. they are macrophages which have become elongated
what should differentials be for postoperative dyspnoea?
atelectasis is a common problem.
also consider pneumonia and PE
how do we confirm a nasogastric tube is correctly placed, on CXR?
ensure it is a sub-diaphragmatic position
how is bronchiectasis managed?
physical inspiratory muscle training and postural drainage= v. important
antibiotics for exacerbations
immunisations
surgeries, bronchodilators in some cases
what is tuberculosis?
a infection with the mycobacterium tuberculosis
most commonly affects the lungs but can affect the whole body
can be primary - acute infection. A Ghon focus (small lung lesion) can develop. it can become fibrosed or develop into miliary Tb (disseminated)
or secondary - reactivation of dormant infection if immunocompromised
