Respiratory Flashcards
Outline some key clinical differences between asthma and COPD:
COPD:
- smokers
- rare <35 years
- Chronic cough is common
- Persistent shortness of breath
- Night symptoms are uncommon
- variability in symptoms is minimal
Asthma is the opposite to all these.
In FBC of COPD what would you expect too see?
polycaethemia
What two infections commonly cause exacerbation of COPD?
H. Influenza
S. Pneumonia
What are some common sites that mesotheliomas have metastasised from?
Ovary
breast
Lymphomas
Define Allergy:
An immune intolerance mediated by the immune system to a particular trigger.
there must be recognition and a response
What is a stridor indicative of?
Inspiration difficulty
Define asthma:
Chronic inflammatory condition of the airways that causes recurrent episodes of wheezing, breathlessness and chest tightening.
- partially reversibly
List come clinical features of asthma:
Wheeze cough sputum is clear breathlessness exercise intolerance
How is asthma diagnosed?
Diary of peak flow
Histamine bronchial Provocation Test
- 20% drop in FEV1
Spirometry
Scratch test
Sputum
- Eosinophil infiltrate
List asthma management:
Stage I: SABA
Stage II: ICS + SABA
Stage III: ICS + LABA + SABA or LRA or theoyphyline or B2 agonist tablet (not <12 years old)
Stage IV: high dose ICS + dialators
+
Antimuscarinic (ipatropium)
Stage V: Oral steroids
+
omalizumab
Mepolizumab
Infliximab
Definition of life threatening asthma attack?
PEF: <33%
SpO2 <92%
Reduced breath sounds
<
Definition of severe asthma attack:
Inability to complete full sentences
PEF: 33-50%
REspiratory rate> 25
Management of severe asthma attack:
Oxygen: 40-60%
Nebulised: salbutamol 5mg
or
Terbutaline 10mg
Prednisolone 40-50mg
or
IV hydrocortisone 100mg
failure in 15-30mins:
- senior help
- contact ICU
IV magnesium 1.2g over 20mins
IV salbutamol
what is the subsequent management of severe asthma attack?
Sats: 94-98%
steroids - 6 hourly
Nebulised B2 4-6 hourly
When can a person be discharged after a severe asthma attack?
24 hour use of medicine with no reductionin PEF.
PEF >75%
Oral and inhaled steroids to be given
Arrangement with GP in 2 days
What is hypersensitivity pneumonitis
Restrictive lung disease characterised by widespread inflammation affecting small airways and alveoli
caused by known allergen.
Outline pathophysiology of Hypersensitivity pneumoitis
first exposure:
Type IV hypersensitivity reaction:
IL12
IFN gama
activation of TH1 cell
Second exposure:
Type III hypersensitivity reaction
reactivation of antibodies.
fibrosis scarring.
complement activation.
Symptoms of hypersensitivity pneumonitis:
Fever
malaise
cough
- after the exposure a few hours later
What is the criteria for obstructive sleep apnea?
The cessation or near cessation of airflow.
> 4% oxygen desaturation lasting >10secs
> 15 episodes of Apnea per hour. (AHI>15)
or
5-15 episodes with compatible symptoms
Symptoms of sleep apnea?
Snorer
Disruptive sleep
Daytim Somnolence
Fatigue
What score can be used in sleep apnea to assess the the distance of the tongue from roof of mouth?
Mallampati score
Investigations into sleep apnea:
Epsworth sleeping score
Limited Polysomnography
Full Polysomnography
Transcutaneous Oxygen Sats
What are the two main differentials for sleep apnea?
Hyponoea:
- reduced oxygen flow but doesn’t meed criteria for sleep apnea
Respiratory effort related arousals
Define interstitial lung disease:
Umbrella term used to describe a group of disorders that lead to scarring lung and restrictive lungs
What are some key medications that can cause intersitial lung disease?
- nitrofurantoin
- DMARDS
- Amiodarone
- ACE inhibitors
- Chemotherapy
- Heroin/ methadone
- Radiation treatment
When assessing for ILD what test should be done?
Chest x-ray
CRP - inflammatory marker
FBC
Immunology
- rheumatoid factor
- Serum ACE (for sarcoid)
ABGs
ECG
What is IPF?
Pulmonary disorder of unknown aetiology that is patchy progress bilateral interstitial fibrosis
Outline pathogenesis of IPF?
Damage to epithelial cells.
Macrophages and neutrophil infiltration
- promote collagen formation
- TGF- Beta
Alveolar epithelium become myoepithlelial cells
- laying down more collagen and leading to restriction
Type II pneumocyte activation, replacement of type I. promotes further inflammation
Clinical findings of IPF?
Velcro-like crackles durign inspiration
CT: Subpleural reticular abnormalities
- honeycombing
- ground glass appearance
What is the histological appearance of IPF? and how is it done?
Done by Video- assisted thoracic surgery
- histology: interstitial pneumonia pattern
- dense fibrosis material in subpleura
- destruction of normal lung
- inflammatory infiltrate
with temporal heterogeneity
Fibroblastic Foci - myofibroblastic proliferation
What is treatment options for IPF?
It is fatal.
Lung transplant needed.
Pirfenidone
- reduced fibrosis formation
Nintedanib
- tryosine kinase inhibitor
N- Acetyl cysteine
- mucus
Oxygen therapy
Antibiotics for infection
When would you not aspirate a pleural effusion?
if bilateral.
- likely to be transudate
What is Light’s criteria for pleural effusion?
Fluid >30g protein
Fluid Lactate dehydrogenase is 2/3rd upper limit of normal plasma
PLeural serum protein ratio >0.5
unilaterally
varying colour
How can malignant pleural effusions be managed?
indwelling pleural catheter
Whats the most common type of hypersensitivty pneumonitis, and what is the pathogen?
Farmer’s lung
micropolyspora faeni
What investigations are done for COPD?
Spirometry with reversibility
Chest x-ray
- hyperinfaltion
- heart looks small
High resolution CT
- bullae
ABGs
- assess for respiratory failure
FBC
- polycaethemia
Alpha -1 antitrypsin
BMI < low associated with worse prognosis
Sputum
- for infections
ECG and Echo
- heart function
Define emphysema:
Abnormal permenant enlargement of the airspaces distal to the terminal bronchioles
What are the dyspnoea scale?
used to assess the level of breathlessness in COPD:
Grade 1: Dyspnoea on strenous activity
Grade 2: Dyspnoea when hurrying or walking up hill
Grade 3: walks slower than others on ground level cause of breathlessness
grade 4: stops for breathes every 100m at ground level
Grade 5: too breathless to leave house. Dressing makes breathless.
What’s an important cytokine in the pathogenesis of IPF?
TGF - Beta
What is the stain used to identified TB? and what is it staining?
Ziehl Neelsen staining
Acid fast bacteria, in TB specifically: Mycolic acid
In TB, what is called when the granuloma forms, and then what is it called when this affects the lymph node aswell?
Ghon focus
Ghon complex
If a patient presents with pneumonia, what microbiology tests should you carry out?
Respiratory samples:
- sputum
- viral PCR from gargle
Urine:
- Legionella - PCR
Blood cultures
MRSA screen
In severe CAP, what is the recommended antibiotics?
IV Amoxicillin or IV co-amoxiclav
+
Clarithromycin
or
Levofloxacin if penicillin allergy
Outwith air conditioners, where else can legionella come about?
compost (soil)
Name another two types of Legionella infections:
Pontiac fever
- acute, self limiting febrile infection
Extra-pulmonary Legionella
- seen in immunocompromised
- myocarditis etc.
Who is most likely to get Mycoplasma Pneumonia?
Young school children
How is Chlamydia Psittaci spread?
Parrots
What type of pneumonia often causes pleural effusions?
S. pneumonia
What are the normal alleles for anti - trypsin and what are the pathological ones, and how do they relate too COPD?
MM - are normal
ZM - heterozygous - will get the disease if smoker
ZZ - homozygous - will get panoemphysema
What investigations are done to assess COPD?
Spirometry - with reversibility
- raised TLC
- Reduced FEV/FVC >.70
Chest X-ray
Sputum analysis
ABGs
- hypoxic
FBC
- polycythemia
When is it considered to be respiratory failure?
<8kPa of oxygen
> 6.7kPa of CO2
Is an allergy dose dependent?
No it is not dose dependant - there is either a reaction or not a reaction.
unlike reactivity to stimulus, which is dose dependent
What are extra- thoracic bronchial disease affected up?
In air problems because they have cartilage which maintains them open - allowing expiration
When diagnosing asthma, using the histamine provocation test, what is the drop in the FEV1 we are looking for?
> 20%
What is considered a small pneumothorax and what is the management of such a small pneumothorax?
<2cm. in healthy people will self heal
- monitor over 7 days
If a pneumothorax is large, what is the size? and what is the management?
> 2cm
Aspiration of air
In the setting of tension pneumothorax, what is the immediate management?
Don’t have time for imaging.
Large IV cannula - insert at 2nd intercostal space at midclavicular line
followed by Chest drain
What are the treatment regimes for COPD?
>50% SABA + a)LABA b)LAMA c) LABA + LAMA d) LABA+ LAMA + ICS
<50% SABA+ a) LABA + ICS b) LAMA c) LABA + ICS + LAMA
Define Obstructive sleep apnea and obstructive sleep apnea syndrome:
Obstructive sleep apnea = recurrent episodes of partial or complete upper airway obstruction with intermittent hypoxia
Syndrome = manifests as the daytime sleepiness
thus if a person has daytime somnolence then they have syndrome time.
What are the main issues associated with OSA?
Heart attack and Strokes
Whats the symptoms of OSA?
Snorer
Witnessed of apnoeas
Disruptive sleep
Daytime somnolence
Low mood
What clinical examination do you do of someone with OSA?
Weight
BMI
BP
Neck circumference
Epworth Sleepiness Score
Home Limited polysomnography
FUll Polysomnography
Transcutaneous Oxygen Saturation and Carbon Dioxide Assessment
Whats the advantages of the Full polysomnography?
Correct patient
Accurate assessment of sleep
EEG
Parasomniac activity - sleep talking, REM
What is severe Sleep apnea?
AHI >30
Who do you treat in sleep apnea?
Obstructive sleep apnea syndrome. i.e. you treat those who have symptoms.
with aim to improve day somnolence and improve quality of life.
What is the treatment of sleep Apnea?
Weight loss
Avoiding triggers - alcohol
Continual positive airway pressure - forces airway opens
What can be used if a patient can’t tolerate CPAP?
Mandibular mouth guard
- pulls the jaw forward
only useful in mild to moderate disease
In hypersensitivity pneumonitis, where is the inflammation?
within the alveolar
List some key findings histological findings of IPF:
Interstitial Pneumonia
fibroblastic focuses
Heterogeneous in nature - varying areas affected.
In asthma outline the main cytokines and described what they do:
Il-4 = activation of Th2
IL 5 = Eosinophils
Il 13 = activates mucus secretion
LT4 = stimulus to the neutrophil and smooth muscle
