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respiratory Flashcards

1
Q

chronic obstructive pulmonary disease

A

progressive airway obstruction with little or no reversibility
FEV1 <80%
FEV1/FVC <70%

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2
Q

COPD: chronic bronchitis

A

epithelial cell layer may ulcerate
when these heal, squamous epithelium may replace columnar
results in chronic cough and phlegm production
‘blue bloaters’

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3
Q

COPD: airway narrowing causes (in chronic bronchitis)

A

bronchial wall inflammation due to irritants- causes scarring
hypertrophy and hyperplasia of mucus secreting glands of bronchial tree- luminal occlusion
mucosal oedema

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4
Q

COPD: chronic bronchitis characteristics

A

submucosal bronchial gland enlargement
goblet cell metaplasia and mucus hypersecretion
airway oedema
inflamed bronchial tree
smooth muscle and connective tissue hypertrophy
airway epithelial squamous metaplasia
ciliary dysfunction

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5
Q

COPD: emphysema

A

dilation and destruction of lung tissue distal to terminal bronchioles
loss of elastic recoil- leads to airflow limitation and air trapping
‘pink puffers’

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6
Q

COPD: emphysema classification

A

centri-acinar emphysema
pan-acinar emphysema
irregular emphysema

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7
Q

COPD: centri-acinar emphysema

A

most common
upper lobe
more concentrated around resp bronchioles, more distal alveolar ducts and alveoli tend to be preserved

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8
Q

COPD: pan-acinar emphysema

A

lower lobe
emphysema affects whole acinus
associated with alpha-1-antitrypsin

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9
Q

COPD: small airway involvement

A

<2mm
involved early in COPD- obstructive bronchiolitis
major site of airway obstruction

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10
Q

COPD: pulmonary vascular changes

A

intimal thickening and endothelial destruction
collagen deposition and breakdown of collagen bed architecture
causes pulmonary hypertension and hypoxia

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11
Q

COPD: pink puffers

A

high alveolar ventilation (compensatory)
near normal PaO2 and normal or low PaCO2
breathless but not cyanosed
can progress to type 1 resp failure

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12
Q

COPD: blue bloaters

A

low alveolar ventilation, low PaO2 and high PaCO2
cyanosed but not breathless
can develop cor pulmonale

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13
Q

COPD: epidemiology

A

10-20% >40 y/o

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14
Q

COPD: causes

A 
cigarette smoke
alpha-1-antitrypsin
cystic fibrosis
industrial irritants
resp infections- cause exacerbations
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15
Q

COPD: smoking

A

> 90%
cause mucus gland hypertrophy and inflammation
inactivates major protease inhibitor alpha-1-antitrypsin

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16
Q

COPD: alpha 1 antitrypsin deficiency

A

cause of early-onset emphysema
tend to have liver disease
low acinar of lungs affected

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17
Q

COPD: risk factors

A 
smoking
pollution
occupational exposures
family history 
increasing age
poor lung development during gestation
severe childhood resp infection
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18
Q

COPD: symptoms

A 
cough
sputum
dyspnoea 
wheeze
lethargy
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19
Q

COPD: signs

A 
tachypnoea
use of accessory muscles of respiration
hyperinflation- barrel shaped chest
wheeze
cyanosis
ankle swelling- if causes heart failure
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20
Q

COPD: complications

A 
acute exacerbations
polycythaemia
resp failure
cor pulmonale- oedema, raised JVP
pneumothorax 
lung carcinoma
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21
Q

COPD investigations: spirometry

A

gold standard
obstruction and air trapping
FEV1 <80%
FEV1/FVC <70%

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22
Q

COPD investigations: CXR

A

hyperinflation
flat hemidiaphragms
large central pulmonary arteries

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23
Q

COPD investigations: FBC

A

increased PCV/haematocrit

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24
Q

COPD investigations: CT

A

bronchial wall thickening
scarring
air space enlargement

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25
COPD investigations: ECG
right atrial and ventricular enlargement
26
COPD investigations: ABG
PaO2 high and normal PaCO2 in pink puffer | PaCO2 high and PaO2 low in blue bloater
27
COPD: lifestyle management
``` information and support smoking cessation exercise diet advice flu vaccination ```
28
COPD: stage 1 treatment
shot acting bronchodilator when needed (SABA= salbutamol) (SAMA= ipratropium bromide)
29
COPD: stage 2 treatment
regular LABA (salmeterol) or LAMA (tiotropium) or LABA +LAMA add pulmonary rehabilitation
30
COPD: stage 3 treatment
LABA+LAMA+ICS (budesonid or beclometasone)
31
COPD: stage 4 treatment
LABA+LAMA+ICS add long term oxygen if in resp failure consider surgery
32
COPD: treatment pathway
nebulised bronchodilators such as salbutamol oxygen therapy if sats <88%- aim for 88-92 steroids- IV hydrocortisone or oral prednisolone antibiotics if sign of infection
33
COPD: treatment for acute exacerbations
mild- short acting bronchodilators moderate- SABA and antibiotics, maybe oral steroids severe- hospitalisation
34
COPD: signs of life threatening resp failure
``` resp rate >30/min use accessory muscles acute changes in mental status persisting hypoxaemia hypercapnia acidosis ```
35
COPD: differentials
``` congestive heart failure bronchiectasis allergic fibrosing alveolitis pneumoconiosis asbestosis asthma ```
36
asthma
reversible chronic obstructive airway disease | hypersensitivity type 1 reaction
37
characteristics of asthma
airflow limitation airway hyper-responsiveness bronchial inflammation
38
non allergic asthma
intrinsic exercise, cold air and stress obesity associated
39
allergic asthma
atopic/eosinophilic extrinsic allergens
40
asthma: three characteristics that contribute to airway narrowing
bronchial muscle contraction mucosal swelling/inflammation- mast cell and basophil degranulation increased mucus production
41
asthma: immediate pathogenesis, IgE mediated type 1 hypersensitivity
- APC phagocytoses allergen and presents on surface as antigen - T-helper binds to antigen and releases cytokines which cause B cells to become plasma cells - Plasma cells release IgE which binds to mast cells - next time allergen enters body it binds to IgE on mast cell which causes it to degranulate
42
asthma: immediate pathogenesis, mast cell degranulation
histamine tryptase prostaglandin 2 cytokines- TNF-alpha, IL-2/4/5_
43
asthma: immediate pathogenesis, histamine and cytokines release
cause: bronchoconstriction mucus production inflammation
44
asthma: long term pathogenesis
airway remodelling: - repeated airway constriction causes smooth muscle hyperplasia and hypertrophy - increased goblet cells caused by mucus gland hyperplasia - thickening of basement membrane - reduced retractile forces
45
asthma: epidemiology
5-8% of population 1/11 children common start is 3-5 y/o
46
asthma: allergic, genetic causes
atopy triad- asthma, hayfever, eczema | atopy= predisposition toward developing certain allergic hypersensitivity reactions
47
asthma: allergic, environmental stimuli
hygiene hypotheses= growing up in clean environment may predispose towards IgE response maternal smoking childhood exposure to allergens
48
asthma: non-allergic causes
stress cold air infection
49
asthma: precipitating factors
``` inflammatory factors irritants smoking/passive smoking drugs- NSAIDs, beta-blockers, ACE-i pollution obesity ```
50
asthma: inflammatory factors
infection | allergens- house dust mite, pollen, fur
51
asthma: irritants
cold air exercise emotion stress
52
asthma: symptoms
``` intermittent dyspnoea wheeze cough sputum chest tightness ```
53
asthma: signs
``` tachypnoea audible wheeze hyperinflated chest hyper-resonant percussion decreased air entry ```
54
asthma: severe attack
inability to complete sentences pulse >110bpm resp rate >25/min PEF 33-50% predicted
55
asthma: life-threatening attack
``` silent chest confusion exhaustion cyanosis bradycardia PEF <33% predicted ```
56
asthma: presentation pattern
diurnal variation worse in morning night time cough
57
asthma treatment: lifestyle
stop smoking avoid allergens education on good inhaler technique and PEF monitoring
58
asthma treatment: step 1
occasional SABA for symptom relief e.g salbutamol | if used more than one daily then step 2
59
asthma treatment: step 2
SABA and inhaled corticosteroids e.g beclometasone
60
asthma treatment: step 3
SABA +ICS + LABA e.g. salmeterol | if still uncontrolled increase ICS dose
61
asthma treatment: step 4
high corticosteroids | consider leukotriene receptor agonist/ modified release theophylline/LAMA
62
asthma treatment: step 5
step 4 + daily oral corticosteroid e.g. prednisolone | refer to asthma clinic
63
asthma treatment: beta- 2-agonists
selective to lungs | relax bronchial smooth muscle by increase cAMP- causes bronchodilation
64
asthma treatment: short acting beta agonist
4 hours salbuatomol can cause tachyarrhythmias
65
asthma treatment: long acting beta agonist
12 hours salmeterol lipophilic so remain in tissue longer same S/E as SABA
66
asthma treatment: corticosteroids
decreased mucosal inflammation | rinse mouth after inhaled to prevent oral candidiasis
67
asthma treatment: theophylline
inhibits phosphodiesterase, decreasing bronchoconstriction by increasing cAMP levels
68
asthma treatment: anticholinergics
decrease muscle spasm | e.g. ipratropium (short term) or tiotropium (long term)
69
asthma treatment: leukotriene receptor antagonist
block effects of cysteinyl leukotrienes in airways | e.g. montelukast
70
asthma: treatment summary
SABA SABA+ICS SABA+ICS+LABA SABA+LABA+high dose ICS+biological therapy SABA+LABA+ HD ICS+ BT+ oral corticosteroid
71
asthma: ABCDE O SHIT ME- acute management
``` ABCDE checks Oxygen- maintain sats 94-98% Salbutamol nebulised Hydrocortisone IV Ipratropium bromide- 4 to 6 hourly Theophylline- usually in ICU Magnesium sulphate- one off dose if life threatening, before doing theophylline Escalate care- intubation and ventilation ```
72
asthma: associated diseases
acid reflux 40-60% polyarthritis nodosa churg-strauss syndrome allergic bronchopulmonary aspergillosis
73
asthma: differentials
``` pulmonary oedema COPD large airway obstruction pneumothorax PE bronchiectasis ```
74
asthma: distinguishing from COPD
COPD later disease- mainly in smokers less day to day variation winter symptoms and sputum production on COPD overlap can occur
75
asthma investigations: RCP3 questions
daytime symptoms effect on daily life difficulty sleeping from cough
76
asthma investigations: initial diagnosis
spirometry, FEV1/FVC <70% reversibility to distinguish from COPD peak flow diary
77
asthma investigations: acute attack
``` PEF sputum culture FBC, U&E, CRP, cultures ABG CXR ```
78
chronic asthma investigations
``` PEF monitoring spirometry CXR skin prick tests to identify allergens histamine challenge aspergillus serology ```
79
bronchial carcinoma: small cell
20%, worse prognosis arise from endocrine cells in central bronchus often secrete polypeptide hormones in paraneoplastic syndrome 70% are disseminated at presentation
80
bronchial carcinoma: non small cell
``` 80% squamous cell carcinoma 35% adenocarcinoma 27% large cell carcinoma 10% adenocarcinoma in situ- rare, <1% ```
81
bronchial carcinoma: non small cell- squamous cell
most strongly associated lung cancer with smoking | arise from epithelial cells
82
bronchial carcinoma: non small cell- adenocarcinoma
most common type most common for non-smokers arise from mucus-secreting glandular cells
83
bronchial carcinoma: sites of metastatic spread
``` liver bone adrenal glands brain pleura and ribs ```
84
bronchial carcinoma: epidemiology
second most common cancer in UK third most common cause of death in UK more common in men
85
bronchial carcinoma: cigarette smoke
causes 90% of lung carcinomas | passive smoking also causes carcinomas
86
bronchial carcinoma: occupational risk factors
``` asbestos chromium arsenic iron oxides coal, nickel, petroleum ```
87
bronchial carcinoma: environmental risk factors
ionising radiation | radon gas
88
bronchial carcinoma: host risk factors
cystic fibrosis | HIV infection
89
bronchial carcinoma: symptoms
``` haemoptysis- red flag cough dyspnoea chest pain weight loss lethargy ```
90
bronchial carcinoma: signs
cachexia- weakness/wasting of the body anaemia clubbing supraclavicular or axillary lymph nodes
91
bronchial carcinoma: chest signs
may be none consolidation collapse pleural effusion
92
bronchial carcinoma: metastatic signs
bone tenderness | hepatomegaly
93
bronchial carcinoma: non metastatic skeletal manifestations
clubbing | hypertrophic osteoarthropathy
94
bronchial carcinoma: non metastatic cutaneous manifestations
dermatomyositis herpes zoster acanthosis nigricans
95
bronchial carcinoma: non metastatic vascular manifestations
thrombophlebitis migrans anaemia disseminated intravascular coagulation
96
bronchial carcinoma: non metastatic neurological manifestations
cerebellar degeneration myopathy polyneuropathy
97
bronchial carcinoma: non metastatic endocrine manifestations
ectopic secretion: ACTH-cushing's ADH- dilutional hyponatraemia TH- hypercalcaemia
98
bronchial carcinoma: local complications
``` recurrent laryngeal nerve palsy phrenic nerve palsy SVC obstruction Rib erosion pericarditis AF ```
99
bronchial carcinoma: metastatic complications
brain bone- anaemia, hypercalcaemia liver adrenals- addison's
100
bronchial carcinoma: non-metastatic neurological complications
``` confusion fits cerebellar syndrom proximal myopathy polymyositis ```
101
bronchial carcinoma: chest x ray
``` peripheral nodule hilar enlargement consolidation lung collapse pleural effusion bony secondaries ```
102
bronchial carcinoma: cytology
sputum and pleural fluid
103
bronchial carcinoma: CT scan
for Staging
104
bronchial carcinoma: bronchoscopy
give histology | assess operability
105
bronchial carcinoma: lung function test
assess suitability for lobectomy
106
bronchial carcinoma: bone scan
if suspected mets
107
bronchial carcinoma: PET scan
helps with staging
108
bronchial carcinoma: non-small cell treatment
surgical excision- lobectomy radiotherapy for stages I-III chemo and radio for more advanced
109
bronchial carcinoma: small cell, treatment
surgery chemo and radio if well enough pharmacological, palliative and treat complications
110
bronchial carcinoma: small cell, palliative care
radiotherapy- for bronchial obstruction, SVC obstruction, haemoptysis, bone pain and cerebral mets
111
bronchial carcinoma: small cell, treat complications
SVC obstruction- stent, RT and dexamethasone endobronchial therapy- tracheal stenting, cryotherapy, laser brachytherapy pleural effusion- drainage
112
bronchial carcinoma: small cell, pharmacological treatment
``` analgesia steroids anti0emetics cough linctus bronchodilators antidepressants ```
113
bronchial carcinoma: prevention
stop smoking | prevent occupational exposure
114
bronchial adenoma: pathology
rare slow growing 90% carcinoid 10% cylindromas
115
bronchial adenoma: treatment
surgery
116
hamartoma: pathology
rare benign irregular proliferations of benign tissues that are not normally found in that pattern within lung tissue
117
hamartoma: investigation
CT- lobulated mass, potential flecks of calcification
118
hamartoma: treatment
excision to exclude malignancy
119
malignant mesothelioma: pathology
malignant tumour of mesothelial cells that usually occurs in the pleura
120
malignant mesothelioma: epidemiology
more common in men | presents 40-70 y/o
121
malignant mesothelioma: aetiology
asbestos is main cause- 90% | latent period can be up to 45 years
122
malignant mesothelioma: symptoms
``` chest pain dyspnoea weight loss fatigue recurrent pleural effusions ```
123
malignant mesothelioma: signs
finger clubbing signs of metastasis- lymphadenopathy, hepatomegaly, bone pain/tenderness abdo pain
124
malignant mesothelioma: investigation
CXR/CT- pleural thickening/effusion aspiration- bloody pleural fluid thorascopy w/ biopsy= diagnostic
125
malignant mesothelioma: treatment
poor prognosis- presents late and progresses quickly, average survival is 8 months chemo can improve survival
126
cancers that spread to the lung
breast bowel kidney bladder
127
causes of nodule in the lung
``` malignancy, primary or secondary abscess granuloma cyst foreign body skin tumour ```
128
complications of resp viruses
``` pharyngitis sinusitis otitis media bronchitis pneumonia ```
129
viral illnesses of resp tract
influenza coronavirus adenovirus respiratory syncytial virus
130
emergency respiratory infections
severe acute respiratory syndrome | avian influenza
131
tonsillitis: pathology
pharyngitis and tonsillitis are infections in the throat that cause inflammation either affecting pharynx or tonsils
132
tonsillitis: viral causes
adenovirus= most common cause rhinovirus epstein barr virus acute HIV infection
133
tonsillitis: bacterial causes
lancefield group A beta-haemolytic streptococci | strep pyogenes
134
tonsillitis: symptoms
sore throat | fever
135
tonsillitis: signs
oropharynx and soft palate are red tonsil inflammation and swelling lymph nodes enlarge
136
tonsillitis: viral presentation
red swollen tonsils | throat redness
137
tonsillitis: bacterial presentation
white pus filled spots grey furry tongue swollen uvula red swollen tonsils and throat
138
tonsillitis: investigations
clinical diagnosis
139
self limiting tonsillitis: treatment
symptomatic treatment- pain relief | no antibiotics required
140
persistent tonsillitis: treatment
phenoxymethylpenicillin | cefaclor
141
sinusitis: pathology
infection of paranasal sinuses | mostly bacterial but can be fungal
142
sinusitis: causes
streptococci pneumoniae= 40% | haemophilus influenzae= 30-35%
143
sinusitis: symptoms
purulent rhinorrhoea facial pain, unilateral with tenderness fever frontal headache
144
sinusitis: signs
past medical history of upper resp tract infection- cold
145
sinusitis: complications
brain abscesses sinus vein thrombosis orbital cellulitis
146
sinusitis: investigations
clinical diagnosis
147
sinusitis: treatment
nasal decongestants- xylometazoline | broad spectrum antibiotics- co-amoxiclav
148
acute epiglottitis: pathology
inflammation of epiglottis
149
acute epiglottitis: causes
haemophilus influenzae= most severe | causes of pharyngitis
150
acute epiglottitis: symptoms
high fever severe airway obstruction odynophagia- pain when swallowing
151
acute epiglottitis: signs
inspiratory stridor- high pitch wheezing when breathing in
152
acute epiglottitis: complications
meningitis septic arthritis osteomyelitis
153
acute epiglottitis: investigations
clinical diagnosis
154
acute epiglottitis: treatment
IV antibiotics- ceftazidime | may require emergency endotracheal intubation
155
whooping cough: pathology
caused by bordatella pertussis- gram -ve coccobacillus highly contagious spread via droplets
156
whooping cough: epidemiology
mainly occurs in childhood | 90% <5 y/o
157
whooping cough: catarrhal phase presentation
``` highly infectious, 1-2 weeks malaise anorexia rhinorrhoea conjunctivitis ```
158
whooping cough: paroxysmal phase presentation
chronic cough >14 days coughing spasms which may end in vomiting classic whoop= breath through partially closed vocal cords
159
whooping cough: complications
pneumonia encephalopathy sub-conjunctival haemorrhage
160
whooping cough: investigations
PCR- nasal/throat swab | culture sensitivity
161
whooping cough: treatment
macrolides- clarithromycin | vaccination in pregnancy
162
croup: pathology
aka acute laryngotracheobronchitis | complication of URTI- particularly from parainfluenza virus and measles
163
croup: pathogenesis
inflammatory oedema extends to vocal cords and epiglottis causes narrowing of airway associated tracheobronchitis progressive airway obstruction
164
croup: symptoms
barking cough- croup
165
croup: signs
hoarse voice audible stridor- high pitch wheeze breathing in tachypnoea cyanosis
166
croup: investigation
clinical diagnosis
167
croup: treatment
nebulised adrenaline oral corticosteroids- dexamethasone oxygen IV fluids
168
pneumonia
acute lower resp tract infection associated with fever, symptoms and signs in the chest and abnormalities on CXR
169
pneumonia: methods of spread
inhalation of airborne particles aspiration of gastric contents or nasopharyngeal flora haematogenous spread- septic arthritis
170
pneumonia: pathogenesis
bacteria translocate in normally sterile distal airway multiply in lung- overwhelm host defence alveolar macrophages release chemicals resulting in inflammation and entry of neutrophils
171
community acquired pneumonia
pneumonia occurs in person with no underlying immunosuppression or malignancy
172
community acquired pneumonia: epidemiology
occurs in all ages but commoner in extremes of age
173
community acquired pneumonia causes: typical
streptococcus pneumonia= most common | haemophilus influenzae
174
community acquired pneumonia causes: atypical
``` water cooler/air conditioner mycoplasma pneumonia staph. aureus legionella chlamydia ```
175
community acquired pneumonia causes: viral
account for 15% CMV VZV SARS
176
hospital acquired pneumonia
defined as >48 hours after hospital admission
177
hospital acquired pneumonia: epidemiology
mostly in elderly, ventilated and post-op | 2nd most common Hospital acquired infection
178
hospital acquired pneumonia causes: common
gram -ve enterobacteria (E.coli, pseudomonas aeruginosa) Staph. aureus
179
hospital acquired pneumonia causes: less common
bacteriodes | clostridia
180
pneumonia causes: aspiration
acute aspiration of gastric contents into lungs | stroke, myasthenia, bulbar palsies, loss of consciousness, poor dental hygiene
181
pneumonia causes: immunocompromised patients
``` pneumocystis jiroveci- HIV strep. pneumonia haemophilus influenzae staph. aureus gram -ve bacilli fungi ```
182
pneumonia: risk factors
``` infants and elderly COPD cystic fibrosis immunocompromised smoking excess alcohol diabetes impaired swallowing CVD ```
183
pneumonia: symptoms
``` fever dyspnoea productive cough purulent sputum pleuritic chest pain haemoptysis ```
184
pneumonia: signs
``` confusion tachypnoea tachycardia hypotension pyrexia cyanosis ```
185
pneumonia: signs of consolidation
reduced expansion dull percussion increased tactile vocal resonance bronchial breathing
186
pneumonia investigations: examination
dull percussion | reduced breath sounds
187
pneumonia investigations: chest x ray
gold standard lobar or multilobar infiltrates pleural effusion
188
pneumonia investigations: microbiology
sputum sample serology pleural fluid aspiration
189
pneumonia investigations: CURB 65
``` Confusion Urea >7mmol/L Resp rate >30/min Bp<90 systolic 65y/o or higher ```
190
pneumonia investigations: CURB 65 implications
0-1=mild, oral antibiotic, home treatment 2= moderate- admit to hospital 3-5= severe=admit and closely monitor 4-5= consider admission to CCU
191
pneumonia treatment: mild community acquired
oral amoxicillin or clarithromycin
192
pneumonia treatment: moderate community acquired
oral amoxicillin or clarithromycin
193
pneumonia treatment: severe community acquired
oral co-amoxiclav or clarithromycin
194
pneumonia treatment: atypical community acquired
legionella- fluoroquinolone and clarithromycin | chlamydia- tetracycline
195
pneumonia treatment: hospital acquired patients
IV aminoglycoside and IV antipseudomonal penicillin
196
pneumonia treatment: aspiration patients
IV cephalosporin and IV metronidazole
197
pneumonia treatment: neutropenic patients
IV aminoglycoside and IV antipseudomonal penicillin
198
pneumonia treatment: supportive therapy
oxygen- keep sats >94% (if COPD, 88-92%) | IV fluids- for anorexia, dehydration and shock
199
pneumonia treatment: analgesia
paracetamol for pleuritic chest pain
200
pneumonia: prevention
smoking cessation influenza vaccine pneumococcal vaccine for at risk groups
201
pneumonia: complications
``` pleural effusion empyema resp failure hypotension AF lung abscess jaundice septicaemia pericarditis brain abscess ```
202
pneumonia complications: pleural effusion
inflammation of pleura by adjacent pneumonia may cause fluid exudation into pleural space if small then no consequences if large or infected then drainage required
203
pneumonia complications: empyema
pus in pleural space should be suspected if a pt. with resolving pneumonia develops a recurrent fever should be drained
204
pneumonia complications: resp failure
type 1 is relatively common | treat with high flow oxygen, aim for normal sats
205
pneumonia complications: hypotension
may be due to combination of dehydration and vasodilation from sepsis treat with IV fluids
206
pneumonia complications: atrial fibrilation
common in elderly usually resolves with treatment of pneumonia beta-blocker or digoxin can be used short term
207
pneumonia complications: septicaemia
may occur as result of bacteria spread from lung into blood stream treat with IV antibiotics according to sensitivities
208
pneumonia complications: Jaundice
usually cholestatic and may be due to sepsis or secondary to antibiotic therapy- especially flucloxacillin and co-amoxiclav
209
pneumonia complications: lung abscess
cavitating area of localised, suppurative infection within the lung
210
pneumonia complications: lung abscess causes
inadequate treat pneumonia aspiration bronchial obstruction septic emboli
211
pneumonia complications: lung abscess presentation
``` swinging fever cough purulent, foul selling sputum malaise finger clubbing anaemia weight loss ```
212
pneumonia complications: lung abscess CXR
walled cavity | often with a fluid level
213
pneumonia complications: lung abscess CT scan
exclude construction
214
pneumonia complications: lung abscess bronchoscopy
obtain diagnostic samples
215
pneumonia complications: lung abscess treatment
antibiotics postural drainage repeated aspiration
216
pneumonia differential diagnosis
TB | lung cancer
217
pneumococcal pneumonia
most common cause of bacterial pneumonia | affects all ages but common in elderly, alcoholics, immunocompromised and chronic heart failure
218
pneumococcal pneumonia: treatment
amoxicillin
219
staphylococcal pneumonia
may complicate influenza infection occurs in young, elderly or those with underlying disease causes bilateral cavitating bronchopneumonia
220
staphylococcal pneumonia: treatment
flucloxacillin | if MRSA- vancomycin
221
klebsiella pneumonia
rare | occurs in elderly, diabetic and alcoholics
222
klebsiella pneumonia: treatment
cefotaxime
223
pseudomonas treatment
antipseudomonal penicillin and aminoglycoside
224
mycoplasma pneumonia treatment
clarithromycin or doxycycline
225
legionella pneumophilia
colonises water tanks kept at 65 degrees | treat with clarithromycin or fluoroquinolone
226
chlamydia pneumonia treatment
clarithromycin or doxycycline
227
viral pneumonia causes
``` influenza= most common swine flu measles CMV varicella zoster ```
228
pneumocystis pneumonia treatment
high dose co-trimoxazole
229
TB: causes
mycobacterium tuberculosis mycobacterium bovis mycobacterium africanum mycobacterium microti
230
TB: bacteria features
M. tuberculosis: - intracellular bacteria - aerobic, non-motile, non-spore forming, slightly curved - slow growing - cell wall contains mycolic acid (phagocytosis resistant) - acid fast bacteria (ziehl-neelsen stain)
231
TB: active infection
occurs when containment by immune system (t cells/macrophages) is inadequate it can arise from primary infection or re-activation of previously latent disease -transmission is via inhalation of aerosol droplets
232
TB: latent pathophysiology
- infection without disease - granuloma forms, preventing bacteria growth and spread - lifetime risk of reactivation is 5-10% - asymptomatic, non-infectious - normal sputum/CXR - positive skin test
233
TB: risk factors for reactivation
``` new infection, <2yrs HIV organ transplant immunosuppression silicosis illicit drug use malnutrition haemodialysis ```
234
TB: risk factors
``` immunocompromised HIV diabetes mellitus IV drug use homeless alcoholic viral hepatitis ```
235
TB presentation: systemic features
``` low grade fever anorexia weight loss malaise night sweats erythema nodosum ```
236
pulmonary TB presentation:
productive cough haemoptysis pleurisy pleural effusion
237
extra-pulmonary TB presentation: lymph
tuberculous lymphadenitis | painless enlargement of cervical or supraclavicular lymph nodes
238
extra-pulmonary TB presentation: GI
``` most disease is ileocaecal colicky abdo pain vomiting bowel obstruction from wall thickening ascites ```
239
extra-pulmonary TB presentation: spinal/bone
local bone pain and tenderness bone destruction vertebral collapse
240
extra-pulmonary TB presentation: milliary
haematogenous dissemination | discrete foci throughout lung (millet appearance)
241
extra-pulmonary TB presentation: CNS
haematogenous spread meningism raised ICP
242
extra-pulmonary TB presentation: GU
dysuria frequency loin pain granulomas can cause infertility, ulceration and strictures
243
extra-pulmonary TB presentation: cardiac
pericardial involvement- pericarditis, pericardial effusion, constrictive pericarditis
244
extra-pulmonary TB presentation: skin
lupus vulgaris- persistent, progressive, cutaneous TB (red brown nodules)
245
latent TB investigations: tuberculin skin testing
intradermal injection of purified protein derivative tuberculin size of skin induration is used to determine positivity
246
latent TB investigations: interferon-gamma release assays
diagnose exposure to TB by measuring the release of interferon-gamma from T-cells reacting to TB antigen
247
active TB investigations: CXR
``` fibronodular, linear opacities in upper lobe cavitation calcification miliary disease effusion ```
248
active TB investigations: sputum smear
Ziehl-neelsen for acid fast bacilli | three specimens are needed
249
active TB investigations: sputum culture
cultured with lowenstein-jensen medium | ziehl-neelsen stain
250
active TB investigations: NAAT
direct detection of M. tuberculosis
251
active TB investigations: histology
caesating granuloma
252
extra-pulmonary TB investigations: aspiration or biopsy
lymph node, pleura, bone, synovium, GI/GU AFB staining histology culture
253
extra-pulmonary TB investigations: NAAT
any sterile fluids- CSF, pericardial | lumbar puncture
254
TB treatment: 1st line treatment RIPE
Rifampicin Isoniazid Pyrazinamide Ethambutol
255
TB treatment: rifampicin
6 months bactericidal blocks protein synthesis
256
TB treatment: isoniazid
6 months bactericidal for rapidly growing bacilli block cell wall synthesis inhibits formation of active vitamin B6 which causes peripheral neuropathy
257
TB treatment: pyrazinamide
2 months | bactericidal
258
TB treatment: ethambutol
2 months | bactericidal
259
TB treatment: rifampicin side effects
Red/orange bodily fluids- urine, sweat, tears renal failure rash hepatitis
260
TB treatment: isoniazid side effects
peripheral neuropathy | tingling, numb feet/hands
261
TB treatment: pyrazinamide side effects
hepatitis | hyperuricaemia/gout
262
TB treatment: ethambutol side effects
Eye problems | optic neuritis
263
TB treatment: side effect management
prophylactic vitamin B6 | eye and liver screening
264
TB: 2nd line treatment
fluoroquinolones- ciprofloxacin augmentin clarithromycin
265
TB: prevention
active case finding | vaccination- BCG
266
respiratory failure
occurs when gas exchange is inadequate, resulting in hypoxia | PaO2 <8kPa
267
type 1 respiratory failure
hypoxia with normal or low PaCO2 | ventilation/perfusion mismatch
268
type 1 respiratory failure causes
V/Q mismatch= pneumonia, pulmonary oedema, pulmonary embolism, asthma, emphysema Hypoventilation Abnormal diffusion
269
type 2 respiratory failure
hypoxia with hypercapnia | caused by hypoventilation w/ or w/o V/Q mismatch
270
type 2 respiratory failure causes: pulmonary disease
asthma COPD pneumonia end stage pulmonary fibrosis
271
type 2 respiratory failure causes: reduced respiratory drive
sedative drugs CNS tumour trauma
272
type 2 respiratory failure causes: neuromuscular disease
cervical cord lesion diaphragmatic paralysis myasthenia gravis guillain-barre syndrome
273
type 2 respiratory failure causes: thoracic wall disease
flail chest | kyphoscoliosis
274
causes of respiratory failure: perfusion
PE cardiac failure shunt pulmonary hypertension
275
causes of respiratory failure: diffusion
IPF | emphysema
276
causes of respiratory failure: hypoventilation
COPD neuromuscular weakness obesity chest wall deformity
277
causes of respiratory failure: obstructive
asthma COPD OSA pneumonia
278
hypoxia: symptoms
``` dyspnoea restlessness agitation confusion central cyanosis ```
279
hypoxia: signs
polycythaemia pulmonary hypertension cor pulmonale
280
hypercapnia: symptoms
``` headache peripheral vasodilation tremor confusion drowsiness ```
281
hypercapnia: signs
bounding pulse tachycardia papilloedema
282
respiratory failure investigations
``` aimed at finding cause ABG CXR sputum culture spirometry ```
283
type 1 resp failure treatment
treat underlying cause oxygen by facemask assisted ventilation if sats remain low
284
type 2 resp failure treatment
***resp centre may be insensitive to CO2 and resp drive is usually because of hypoxia*** treat cause controlled oxygen therapy- aim for 88-92% sats recheck ABG after 20 mins
285
ABG result of metabolic alkalosis:
``` pH= high PaCO2= normal, high when compensated HCO3-= high ```
286
ABG result of metabolic acidosis:
pH= low PaCO2=normal, low when compensated HCO3-=low
287
ABG result of resp alkalosis:
pH= high PaCO2= low HCO3-=normal, low when compensated
288
ABG result of resp acidosis:
``` pH= low PaCO2= high HCO3-= normal/high when compensated ```
289
interstitial lung disease pathology
generic term to describe conditions affecting mainly ling parenchyma in a diffuse manner chronic inflammation and/or progressive interstitial fibrosis
290
interstitial lung disease clinical features
dyspnoea on excretion non-productive cough abnormal breathing sounds abnormal chest x ray or CT
291
interstitial lung disease pathological features
fibrosis and remodelling of interstitium chronic inflammation hyperplasia of type II pneumocytes
292
interstitial lung disease with known cause
``` occupational/environmental- asbestos, cotton worker lung etc. drugs hypersensitivity reactions infections- TB gastro-oesophageal reflux ```
293
interstitial lung disease associated with systemic disorders
sarcoidosis RA SLE
294
idiopathic interstitial lung disease
idiopathic pulmonary fibrosis | non-specific interstitial pneumonitis
295
causes of fibrotic shadowing on CXR: upper zone
TB hypersensitivity pneumonitis ankylosing spondylitis Radiotherapy
296
causes of fibrotic shadowing on CXR: mid zone
sarcoidosis | histoplasmosis
297
causes of fibrotic shadowing on CXR: lower zone
idiopathic pulmonary fibrosis | asbestosis
298
hypersensitivity pneumonitis
hypersensitivity reaction to inhaled allergens- affecting small airways and alveoli. Type 3 hypersensitivity reaction due to immune complex deposition
299
hypersensitivity pneumonitis: pathogenesis
in sensitised individuals, repetitive inhalation of allergens provokes a hypersensitivity reaction. This varies in intensity and clinical course depending on the allergen
300
hypersensitivity pneumonitis: acute phase
alveoli are infiltrated with acute inflammatory cells | results in pneumonitis
301
hypersensitivity pneumonitis: chronic phase
granuloma formas and obliterative bronchiolitis | results in fibrosis, emphysema, and permanent lung damage
302
hypersensitivity pneumonitis causes: farmer's/ mushroom worker's lung
due to exposure of mouldy hay | bacteria= micropolyspora faeni, thermoactinomyces vulgaris
303
hypersensitivity pneumonitis causes: pigeon-fancier's lung
due to exposure of avian proteins in bird droppings
304
hypersensitivity pneumonitis causes: malt worker's lung
due to exposure of aspergillus clavatus
305
hypersensitivity pneumonitis causes: bagassosis or sugar worker's lung
due to exposure of thermoactinomyces sacchari
306
hypersensitivity pneumonitis causes: cheese worker's lung
due to exposure of mouldy cheese- penicillium casei
307
hypersensitivity pneumonitis: risk factors
pre-existing lung disease specific occupations bird keeping regular hot tub use
308
acute hypersensitivity pneumonitis: presentation
``` 4-6 hr post exposure fever rigors myalgia dry cough dyspnoea fine bilateral crackles ```
309
chronic hypersensitivity pneumonitis: symptoms
increasing dyspnoea weight loss exertional dyspnoea
310
chronic hypersensitivity pneumonitis: signs
finger clubbing type 1 resp failure cor pulmonale
311
acute hypersensitivity pneumonitis investigations: bloods
serum antibodies- may indicated exposure and previous sensitisation rather than disease
312
acute hypersensitivity pneumonitis investigations: CXR
upper zone mottling/consolidation
313
acute hypersensitivity pneumonitis investigations: lung function tests
reversible restrictive defect | reduced gas transfer during attack
314
chronic hypersensitivity pneumonitis investigations: bloods
serum antibodies
315
chronic hypersensitivity pneumonitis investigations: CXR
upper zone fibrosis | honey comb lung
316
chronic hypersensitivity pneumonitis investigations: CT chest
nodules ground glass appearance fibrosis
317
chronic hypersensitivity pneumonitis investigations: lung function test
restrictive defect
318
chronic hypersensitivity pneumonitis investigations: bronchoalveolar lavage
fluid shows an increase in lymphocytes and plasma cells
319
acute hypersensitivity pneumonitis: treatment
remove allergen give oxygen oral prednisolone
320
chronic hypersensitivity pneumonitis: treatment
allergen avoidance | long term steroids
321
hypersensitivity pneumonitis: differentials
infection connective tissue disorder pulmonary fibrosis asthma
322
occupational lung disorders
response to inhalation of fumes, dust, gas or vapour at work
323
occupational lung disorders: acute bronchitis
from irritants such as sulphur dioxide, chlorine, ammonia, oxides of nitrogen
324
occupational lung disorders: pulmonary fibrosis
from inhalation of inorganic dust- coal, silica, asbestos, iron, tin
325
occupational lung disorders: occupational asthma
most common industrial lung disease in developed world
326
occupational lung disorders: bronchial carcinoma
due to asbestos, polycyclic hydrocarbons, radon mines
327
coal workers pneumoconiosis
pneumoconiosis is accumulation of dust in the lungs and reaction of the tissue
328
coal workers pneumoconiosis: pathology
most common dust disease in countries with coal mines results in inhalation of coal dust over 15-20 years these are ingested by macrophages which die, releasing enzymes that cause fibrosis
329
coal workers pneumoconiosis: presentation
asymptomatic | co-existing bronchitis is common
330
coal workers pneumoconiosis: investigations
chest x ray- round opacities, especially upper lobe
331
coal workers pneumoconiosis: treatment
avoid coal dust exposure | treat chronic bronchitis
332
progressive massive fibrosis
due to progression of coal workers pneumoconiosis
333
progressive massive fibrosis: presentation
progressive dyspnoea fibrosis cor pulmonale
334
progressive massive fibrosis: investigations
CXR- bilateral, upper-mid zone fibrotic masses | develop from periphery to hilum
335
progressive massive fibrosis: treatment
avoid coal dust exposure
336
silicosis
caused by inhalation of silica particles which are very fibrogenic jobs include- metal mining, stone quarrying, sand blasting, pottery
337
silicosis: presentation
progressive dyspnoea | high incidence of TB
338
silicosis: investigations
CXR- diffuse miliary/nodular pattern in upper-mid zones, egg shell calcification of hilar nodules Spirometry- restrictive ventilatory defect
339
silicosis: treatment
avoid silica exposure
340
asbestosis
inhalation of asbestos fibres the degree of roofing exposure related to degree of fibrosis high risk of bronchial adenocarcinoma and mesothelioma
341
asbestosis: presentation
``` similar to other fibrotic lung diseases progressive dyspnoea clubbing fine end-inspiratory crackles pleural plaques ```
342
asbestosis: treatment
symptomatic treatment- corticosteroids
343
berylliosis
caused by inhalation of beryllium | copper alloy used in aerospace industry, atomic reactors and electrical devices
344
byssinosis
caused by prolonged inhalation of textile fibre dust- cotton | chest tightness, cough, dyspnoea
345
idiopathic pulmonary fibrosis
progressive chronic pulmonary fibrosis of unknown aetiology | most common cause of interstitial lung disease
346
idiopathic pulmonary fibrosis: pathogenesis
thought to develop from repetitive injury to alveolar epithelium wound healing mechanisms become uncontrolled leading to overproduction of fibroblasts patchy fibrosis occurs in interstitium structural integrity of parenchyma is lost as well as elasticity
347
idiopathic pulmonary fibrosis: risk factors
factors that trigger aberrant wound healing: | cigarette smoke, infectious agents (hep C), occupational dust exposure, drugs (methotrexate) GORD
348
idiopathic pulmonary fibrosis: symptoms
dry cough exertional dyspnoea malaise weight loss
349
idiopathic pulmonary fibrosis: signs
cyanosis finger clubbing fine end-inspiratory crepitation
350
idiopathic pulmonary fibrosis: complications
resp failure | increased risk of lung cancer
351
idiopathic pulmonary fibrosis: bloods
high CRP high immunoglobulins ABG- low PaO2
352
idiopathic pulmonary fibrosis: CXR
bilateral lower zone reticulo-nodular shadows | honeycomb lung
353
idiopathic pulmonary fibrosis: Chest CT
similar to XR but more sensitive and essential for diagnosis
354
idiopathic pulmonary fibrosis: spirometry
restrictive
355
idiopathic pulmonary fibrosis: bronchoalveolar lavage
high lymphocytes- good prognosis | high neutrophils and eosinophils- poor prognosis
356
idiopathic pulmonary fibrosis: lung biopsy
may be needed for diagnosis
357
idiopathic pulmonary fibrosis: supportive care
oxygen pulmonary rehab opiates palliative care
358
idiopathic pulmonary fibrosis: treatment
lung transplant | DO NOT give high dose steroids
359
idiopathic pulmonary fibrosis: differentials
``` COPD asthma congestive heart failure pneumonia lung cancer asbestosis hypersensitivity pneumonitis ```
360
sarcoidosis
multisystem granulomatous disorder of unknown cause
361
sarcoidosis: pathogenesis
typical sarcoid granulomas consist of focal accumulations of epitheloid cells, macrophages and lymphocytes affects any organ system
362
sarcoidosis: histology
non-caseating granuloma (aggregation of epitheloid histiocytes)
363
sarcoidosis: epidemiology
affects adults, 20-40 y/o more common in women afro-caribbeans are more affected
364
acute sarcoidosis: presentation
``` usually resolves spontaneously fever erythema nodosum polyarthralgia bilateral hilar lymphadenopathy ```
365
sarcoidosis: pulmonary symptoms
``` dry cough progressive dyspnoea decreased exercise intolerance chest pain abnormal CXR ```
366
sarcoidosis: non-pulmonary signs
``` lymphadenopathy hepatomegaly splenomegaly uveitis conjunctivitis neuropathy space occupying lesions arrhythmia renal stones ```
367
sarcoidosis presentation: SARCOID
Skin- erythema nodosum Arthritis- hands and feet Respiratory- BHL Cardiac- heart block, heart failure Ocular- anterior uveitis Intracranial- chronic meningitis, seizures Derangement of liver and renal function- hypercalcaemia
368
sarcoidosis investigations: bloods
``` high ESR lymphopenia high LFT high serum ACE high calcium ```
369
stage 0 sarcoidosis investigations: CXR
normal
370
stage 1 sarcoidosis investigations: CXR
BHL
371
stage 2 sarcoidosis investigations: CXR
BHL and peripheral pulmonary infiltrates
372
stage 3 sarcoidosis investigations: CXR
peripheral pulmonary infiltrates
373
stage 4 sarcoidosis investigations: CXR
progressive pulmonary fibrosis bulla formation pleural involvement
374
sarcoidosis investigations: ECG
arrhythmias | BBB
375
sarcoidosis investigations: lung function tests
may be normal potential reduced lung volumes impaired gas transfer and a restrictive ventilatory impairment
376
sarcoidosis investigations: bronchoalveolar lavage
shows increase in lymphocytes in active disease | increase in neutrophils in pulmonary fibrosis
377
sarcoidosis investigations: ultrasound
may show nephrocalcinosis or hepatosplenomegaly
378
sarcoidosis investigations: bone X ray
punched out lesions in terminal phalanges
379
sarcoidosis investigations: CT/MRI
may be useful in assessing severity of pulmonary disease or diagnosing neuro-sarcoidosis
380
acute sarcoidosis: treatment
bed rest | NSAIDS
381
stages I-III sarcoidosis: treatment
remission likely
382
stage IV sarcoidosis: treatment
corticosteroids- prednisolone | if parenchymal lung disease/uveitis/hypercalcaemia/neuro or cardio involvement
383
severe sarcoidosis: treatment
IV methylprednisolone immunosuppressants- methotrexate anti-TNF-alpha lung transplant
384
differentials for sarcoidosis
``` RA lymphoma metastatic malignancy TB lung cancer SLE idiopathic pulmonary fibrosis multiple myeloma ```
385
differentials for granulomatous disease: infections
bacterial- TB, leprosy, syphilis fungi- cryptococcus neoformans protozoa
386
differentials for granulomatous disease: autoimmune
primary biliary cholangitis | granulomatous orchitis
387
differentials for granulomatous disease: vasculitis
giant cell arteritis | polyarteritis nodosa
388
differentials for granulomatous disease: idiopathic
crohn's disease | sarcoidosis
389
causes of bilateral hilar lymphadenopathy
``` sarcoidosis infection- TB malignancy- lymphoma organic dust disease- silicosis hypersensitivity pneumonitis ```
390
bronchiectasis
chronic inflammation of the bronchi and bronchioles, leading to permanent dilation and thinning of these airways
391
bronchiectasis: characteristics
irreversible dilation of the bronchioles- due to recurrent damage and inflammation build-up of mucus increasing risk of infection ciliary dysfunction
392
bronchiectasis: pathogenesis
``` damage to bronchi and bronchioles widening due to scarring and inflammation increased mucus production stagnant bacteria cause infection damage to the tract widening cycle continues ```
393
bronchiectasis: main organisms
H. influenzae pseudomonas aeruginosa strep. pneumoniae staph. aureus
394
bronchiectasis: epidemiology
more common in women
395
bronchiectasis: post-infection causes
``` most common previous pneumonia TB measles whooping cough bronchiolitis HIV ```
396
bronchiectasis: congenital causes
CF | young's syndrome
397
bronchiectasis: other causes
``` bronchial obstruction- tumour, foreign body allergic bronchopulmonary aspergillosis RA Ulcerative colitis idiopathic ```
398
bronchiectasis: symptoms
persistent cough copious purulent sputum intermittent haemoptysis dyspnoea
399
bronchiectasis: signs
finger clubbing coarse inspiratory crepitations wheeze
400
bronchiectasis: complications
pneumonia pleural effusion pneumothorax amyloidosis
401
bronchiectasis: high resolution CT
gold standard asses extent and distribution of disease thickened, dilated bronchi (larger than associated blood vessels) and cysts at end of bronchioles
402
bronchiectasis: sputum culture
look for infectious agents
403
bronchiectasis: CXR
cystic shadows | thickened bronchial walls
404
bronchiectasis: spirometry
often shows an obstructive pattern | reversibility should be assessed
405
bronchiectasis: bronchoscopy
locate site of haemoptysis | exclude obstruction and obtain samples for culture
406
bronchiectasis: non-pharmacological treatment
can't be cured. stop smoking vaccinations for infections airway clearance techniques- physio, flutter valves
407
bronchiectasis: pharmacological treatment
bronchodilators- nebulised salbutamol corticosteroids- prednisolone antibiotics- according to sensitivities (amoxicillin for H. influenzae, flucloxacillin for s. aureus)
408
bronchiectasis: surgery
may be indicated in localised disease or to control severe haemoptysis
409
bronchiectasis: differentials
``` COPD asthma TB cough due to acid reflux pneumonia cancer inhalation of foreign body ```
410
cystic fibrosis (CF)
chronic disease resulting in thickened and sticky mucus
411
CF: genetics
autosomal recessive | mutation in CF transmembrane conductance regulator (CFTR) gene on chromosome 7
412
CF: pathogenesis
mutation in CFTR Cl- channel protein Cl- cannot be transported into lumen water does not move out by osmosis
413
CF: characteristics
thick and sticky mucus which blocks ducts affects all ducts that produce mucus predisposes lung to chronic infections
414
CF: epidemiology
one of the most common life-threatening autosomal recessive conditions presents in childhood
415
CF: aetiology
mutation in CFTR gene on chromosome 7 | F508 deletion is most common- 70%
416
CF: risk factors
family history | caucasian
417
CF: neonate presentation
failure to thrive meconium ileus rectal prolapse
418
CF: resp symptoms
``` cough wheeze recurrent infections bronchiectasis pneumothorax resp failure ```
419
CF: GI symptoms
pancreatic insufficiency- diabetes, steatorrhoea | distal intestinal obstruction syndrome
420
CF: other symptoms
``` male infertility osteoporosis arthritis vasculitis nasal polyps ```
421
CF: signs
cyanosis finger clubbing bilateral coarse crackles
422
CF complications
infertility pancreatitis resp infections bronchiectasis
423
CF investigations: sweat test
diagnostic sweat sodium and chloride >60mmol/L abnormal NaCl collected as it can't be pumped into lumen so removed via skin
424
CF investigations: genetic testing
diagnostic | screen for common CF mutations
425
CF investigations: faecal elastase
screening test in newborns | low or no levels of elastase- marker for exocrine pancreatic dysfunction
426
CF treatment
no cure symptomatic management life expectancy of about 50 years
427
CF non-pharmacological treatment
physiotherapy- postural drainage, airway clearance techniques
428
CF pharmacological treatment
``` antibiotics mucolytics bronchodilators pancreatic enzyme replacement fat soluble vitamin supplements- A,D,E,K ursodeoxycholic acid ```
429
CF pharmacological treatment: antibiotics
for acute infective exacerbations prophylactically flucloxacillin for s. aureus amoxicillin for H. influenzae
430
CF pharmacological treatment: mucolytics
clear airways of mucus | DNase e.g. dornase alpha
431
CF pharmacological treatment: bronchodilators
salbutamol and beclometasone | symptom relief
432
CF pharmacological treatment: treat complications
CF related diabetes- insulin osteoporosis- bisphosphonates malabsorption, GORD, fertility
433
CF surgery
lung transplant
434
CF monitoring
annual chest x ray | screening for osteoporosis- DEXA scan
435
CF, advanced lung disease: treatment
oxygen diuretic non-invasive ventilation lung and heart transplants
436
pleural effusion: haemothorax
blood in pleural space
437
pleural effusion: empyema
pus in pleural space
438
pleural effusion: chylothorax
chyle (lymph with fat) in pleural space
439
pleural effusion: haemopneumothorax
both blood and air in pleural space
440
pleural effusion: exudate
protein conc. >35g/L
441
pleural effusion: transudate
protein conc. <25g/L
442
pleural effusion: transudate pathogenesis
excessive production of pleural fluid or resorption of the fluid is reduced mostly due to fluid being pushed out of the vessels and into the space
443
pleural effusion: exudate pathogenesis
results from damaged pleura | mostly due to increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy
444
pleural effusion: increased venous pressure, transudate causes
heart failure constrictive pericarditis fluid overload
445
pleural effusion: hypoproteinaemia transudate causes
cirrhosis nephrotic syndrome malabsorption
446
pleural effusion: other transudate causes
hypothyroidism | meig's syndrome- R pleural effusion and ovarian fibrom
447
pleural effusion: exudate causes
``` pneumonia TB PE lung cancer SLE RA ```
448
pleural effusion: risk factors
previous lung damage | asbestos exposure
449
pleural effusion: symptoms
can be asymptotic dyspnoea pleuritic chest pain
450
pleural effusion: signs
decreased expansion stony dull percussion notes diminished breath sounds
451
pleural effusion: signs of associated disease
``` malignancy- clubbing, lymphadenopathy stigmata of chronic liver disease cardiac failure hypothyroidism RA SLE- butterfly rash ```
452
pleural effusion investigation: CXR
white fluid small effusions blunt the costophrenic angles larger effusions are seen as water-dense shadows with concave upper borders
453
pleural effusion investigation: ultrasound
useful in identifying the presence of pleural fluid and guiding diagnostic or therapeutic aspiration
454
pleural effusion investigation: diagnostic aspiration
clinical chemistry (protein, glucose, pH), bacteriology (TB culture, MC&C), cytology, immunology
455
pleural effusion investigation: pleural biopsy
if pleural fluid analysis is inconclusive
456
pleural effusion treatment
``` treat cause drainage pleurodesis intra-pleural alteplase and dornase alpha surgery ```
457
pleural effusion treatment: drainage
small needle or tube inserted and draws out the fluid
458
pleural effusion treatment: pleurodesis
recurrent effusions for more severe cases | injection of 'glue', the two pleural surfaces stick together so no more fluid can come in between
459
pleural effusion treatment: intra-pleural alteplase and dornase alpha
IPA= thrombolytic, DA= mucolytic | may help empyema
460
pleural effusion treatment: surgery
persistent collections and increasing pleural thickness on USS requires surgery
461
pneumothorax
air in pleural space | causes lung on affected side to collapse and is unable to inflate
462
simple pneumothorax
no communication with atmosphere no mediastinal shift non-expanding pleural cavity pressure less than atmosphere
463
tension pneumothorax
progressive build up of air in pleural space from each inspiration mediastinum is pushed over into contralateral hemithorax can lead to cardiorespiratory arrest
464
communicating pneumothorax
loss of integrity of a chest wall, secondary to penetrating chest trauma causes collapse of affected lung on inspiration
465
pneumothorax: primary spontaneous causes
young thin men- connective tissue disorders, marfan's, elhers-danlos due to rupture of subpleural bulla- thing walled air containing spaces usually apical- due to congenital defects
466
pneumothorax: secondary spontaneous causes
chronic lung disease- asthma, COPD, FC, sarcoidosis infection- TB, pneumonia carcinoma
467
pneumothorax: traumatic causes
traumatic- fractured rib, stab wound, gunshot | iatrogenic- CVP line insertion, pleural aspiration
468
pneumothorax: risk factors
``` male smoking tall underweight use of mechanical ventilation ```
469
pneumothorax: symptoms
``` can be asymptomatic sudden onset of dyspnoea pleuritic chest pain sudden deterioration hypoxic ```
470
pneumothorax: signs
reduced expansion hyper-resonance to percussion diminished breath sounds
471
tension pneumothorax: signs
``` respiratory distress tachycardia hypotension distended neck veins trachea deviation away from side of pneumothorax ```
472
pneumothorax: CXR
should not be performed if suspected tension as it delays treatment look for an area devoid of lung markings, peripheral to edge of collapsed lung
473
pneumothorax: ABG
if dyspnoeic/chronic lung disease | hypoxia
474
small spontaneous pneumothorax: treatment
heal on their own
475
pneumothorax due to trauma or medical intervention: treatment
chest drain
476
tension pneumothorax: treatment
needle aspiration then chest drain
477
pneumothorax: surgery
if: bilateral lung fails to expand in 48 hours of drain insertion persistent air leak
478
pneumothorax: differentials
pleural effusion chest pain pulmonary embolism
479
pulmonary embolism
blockage of pulmonary artery or one of its branches in the lung by a venous thromboembolism
480
pulmonary embolism: pathogenesis
PEs usually arise from a venous thrombosis in pelvis or legs | clots break off and pass through the veins and right side of heart before lodging in pulmonary circulation
481
pulmonary embolism: risk factors and causes
``` deep vein thrombosis septic emboli fat air recent surgery leg fracture malignancy old age obesity combined pill ```
482
pulmonary embolism: symptoms
acute dyspnoea pleuritic chest pain haemoptysis syncope
483
pulmonary embolism: signs
``` cyanosis tachypnoea tachycardia hypotension pleural effusion ```
484
pulmonary embolism: bloods
FBC U&E baseline clotting
485
pulmonary embolism: D-dimer
non-specific fibrin degradation product normal excludes diagnosis positive does not confirm
486
pulmonary embolism: ABG
may show type 1 resp failure, low O2 and low Co2
487
pulmonary embolism: CXR
may be normal or show dilated pulmonary artery, or pleural effusion
488
pulmonary embolism: CT pulmonary angiography
sensitive and specific | test of choice in high risk or those with positive D-dimer
489
pulmonary embolism: ECG
may be normal or show tachycardia, RBBB, RV strain
490
pulmonary embolism: treatment
``` LMHW thrombolysis anticoagulants oxygen morphine IV fluids ```
491
pulmonary embolism: LMWH
short term anticoagulation | fondaparinux
492
pulmonary embolism: thrombolysis
if haemodynamically unstable | alteplase
493
pulmonary embolism: long term anticoagulants
DOAC- rivaroxaban- inhibit factor Xa | warfarin
494
pulmonary embolism: length of treatment
pregnancy- LMWH until delivery malignancy- LMWH for 6 months or until cure of cancer unprovoked- continue for > 3 months provoked- 3 months then reassess risk
495
pulmonary embolism: prevention
LMWH to all immobilised patients stop HRT and combined pill hydration early mobilisation
496
wegener's granulomatosis
multisystem disorder of unknown cause characterised by necrotising granulomatous inflammation and vasculitis of small and medium vessels
497
wegener's granulomatosis: pathogenesis
anti-neutrophil cytoplasmic antibody (ANCA) attaches to neutrophils and activated them before then enter the tissue this results in recruitment of more neutrophils and so more activation reactive oxygen species produced and neutrophil degranulation occurs this generates microabscesses, recruits monocytes and produces granulomas by macrophages
498
wegener's granulomatosis: upper airway disease presentation
nasal obstruction ulcers nose bleed destruction of nasal septum
499
wegener's granulomatosis: renal disease presentation
rapidly progressive glomerulonephritis proteinuria haematuria
500
wegener's granulomatosis: pulmonary involvement presentation
cough haemoptysis pleuritic chest pain
501
wegener's granulomatosis: general presentation
skin purpura peripheral neuropathy arthritis
502
wegener's granulomatosis: bloods
cANCA positive | high ESR/CRP
503
wegener's granulomatosis: urinalysis
look for proteinuria and haematuria
504
wegener's granulomatosis: CXR
nodules present | possible fluffy infiltrate of pulmonary hemorrhage
505
wegener's granulomatosis: CT
diffuse alveolar haemorrhage
506
wegener's granulomatosis: treating severe disease
corticosteroids- prednisolone- induces remission | methotrexate for maintenance
507
wegener's granulomatosis treatment: plasma exchange
severe renal disease or pulmonary haemorrhage
508
wegener's granulomatosis treatment: co-trimoxazole
prophylaxis against pneumocystis jiroveci and staph colonisation
509
wegener's granulomatosis: differentials
churg-strauss syndrome: - affects small arteries - males in 40s - rhinitis, eosinophilia and vasculitis - high eosinophil count - ANCA +ve
510
goodpasture's syndrome: epidemiology
more common in males | usually presents >16 yrs
511
goodpasture's syndrome: lung disease presentation
``` pulmonary haemorrhage sneezing, nasal discharge, fever cough dyspnoea anaemia ```
512
goodpasture's syndrome: acute glomerulonephritis presentation
nephritic glomerulonephritis haematuria proteinuria hypertension
513
goodpasture's syndrome: autoantibodies
diagnostic test | anti-GBM
514
goodpasture's syndrome: CXR
infiltrates due to pulmonary haemorrhage- often in lower zones
515
goodpasture's syndrome: kigney biopsy
crescent glomerulonephritis
516
goodpasture's syndrome: treatment
vigorous immunosuppressants treat shock plasma exchange
517
goodpasture's syndrome treatment: vigorous immunosuppressants
corticosteroids- prednisolone | cyclophosphamide
518
goodpasture's syndrome: differentials
SLE RA idiopathic pulmonary haemosiderosis
519
goodpasture's syndrome
acute glomerulonephritis and lung symptoms caused by antiglomerular basement membrane antibodies type 2 hypersensitivity autoimmune disease
520
acute respiratory distress syndrome
caused by direct lung injury or occur secondary to severe systemic illness lung damage and release of inflammatory mediators cause increased capillary permeability and non-cariogenic pulmonary oedema
521
acute respiratory distress syndrome: pulmonary causes
``` pneumonia gastric aspiration inhalation injury vasculitis ```
522
acute respiratory distress syndrome: other causes
``` shock septicaemia haemorrhage multiple transfusions acute liver failure trauma burns ```
523
acute respiratory distress syndrome: risk factors
``` sepsis trauma pneumonia gastric aspirin pregnancy drugs burns smoke inhalation head injury raised ICP malaria ```
524
acute respiratory distress syndrome: symptoms
cyanosis | peripheral vasodilation
525
acute respiratory distress syndrome: signs
tachypnoea tachycardia bilateral fine inspiratory crackles
526
acute respiratory distress syndrome: investigations
blood test ABG CXR pulmonary artery catheter
527
acute respiratory distress syndrome: CXR
bilateral pulmonary infiltrates
528
acute respiratory distress syndrome: pulmonary artery catheter
measure pulmonary capillary wedge pressure- normal
529
acute respiratory distress syndrome: diagnostic criteria
the following: - acute onset - CXR- bilateral infiltrates - PCWP normal - refractory hypoxaemia with PaO2:FiO2 <200
530
acute respiratory distress syndrome: treatment
``` admit to ITU supportive therapy treat cause nutritional support resp and circulatory support treat sepsis ```
531
acute respiratory distress syndrome treatment: respiratory support
1st line- continuous positive airway pressure with 40-60% O2 | 2nd line- mechanical ventilation
532
acute respiratory distress syndrome treatment: circulatory support
conservative fluid management inotropes, vasodilators, blood transfusions low dose NO to treat hypertension
533
acute respiratory distress syndrome treatment: sepsis
identify organism | give appropriate antibiotics
534
pulmonary hypertension
mean pulmonary artery pressure above 25mmHg | occurs due to increased pulmonary vascular resistance or increased pulmonary blood flow
535
pulmonary hypertension: pathogenesis
hypoxic vasoconstriction, inflammation or cell proliferation results in narrower vessels increasing right ventricular pressure causing hypertension. leads to development of RV hypertrophy, dilation and eventually failure
536
pulmonary hypertension: pulmonary vascular disorders causes
pulmonary embolism | primary pulmonary hypertension
537
pulmonary hypertension: disease of lung parenchyma causes
COPD | chronic lung disorders
538
pulmonary hypertension: MSK disorders causes
poliomyelitis | myasthenia gravis
539
pulmonary hypertension: disturbance of resp drive causes
obstructive sleep apnoea morbid obesity cerebrovascular disease
540
pulmonary hypertension: cardiac causes
mitral stenosis LV failure congenital heart failure
541
pulmonary hypertension: symptoms
``` exertional dyspnoea lethargy fatigue ankle swelling chest pain ```
542
pulmonary hypertension: signs
loud pulmonary second sound | right parasternal heave
543
pulmonary hypertension investigations: CXR
enlarged proximal pulmonary arteries which taper distally
544
pulmonary hypertension investigations: ECG
RVH and P pulmonale | right axis deviation
545
pulmonary hypertension investigations: echo
RV dilation
546
pulmonary hypertension investigations
``` LFT detects portal hypertension autoimmune screen Echo ECG CXR ```
547
pulmonary hypertension: treatment
``` treat cause oxygen warfarin diuretics for oedema pulmonary vasodilators ```
548
pulmonary hypertension: differentials
``` cor pulmonale cardiomyopathies primary right ventricular heart failure congestive cardiac failure portal hypertension ```
549
cor pulmonale
right heart failure and abnormal enlargement | caused by chronic pulmonary arterial hypertension
550
cor pulmonale: caused by lung disease
COPD bronchiectasis pulmonary fibrosis lung resection
551
cor pulmonale: caused by pulmonary vascular disease
pulmonary emboli pulmonary vasculitis ARDS sickle cell
552
cor pulmonale: caused by thoracic cage abnormality
hyphosis scoliosis thoracoplasty
553
cor pulmonale: neuromsuclar disease
myasthenia gravis poliomyelitis motor neuron disease
554
cor pulmonale: hypoventilation
sleep apnoea | enlarged adenoids
555
cor pulmonale: symptoms
dyspnoea fatigue syncope
556
cor pulmonale: signs
``` cyanosis tachycardia raised JVP loud P2 pansystolic murmur ```
557
cor pulmonale: bloods
FBC- high haematocrit, secondary polycythaemia
558
cor pulmonale: ABG
hypoxia | hypercapnia
559
cor pulmonale: CXR
enlarged right atrium and ventricle, prominent pulmonary arteries
560
cor pulmonale: ECG
P pulmonale right axis deviation right ventricular hypertrophy
561
cor pulmonale: treat cause
COPD | pulmonary infections
562
cor pulmonale: treating resp failure
in acute situation | give 24% oxygen
563
cor pulmonale: treating cardiac failure
diuretics- furosemide
564
cor pulmonale: venesection treatment
if haematocrit >55%
565
cor pulmonale: surgery
if the patient is young | heart-lung transplant
566
beta 2 agonists: indications
COPD asthma
567
beta 2 agonists: examples
salbutamol- SABA | salmeterol- LABA
568
beta 2 agonists: route of administration
inhaler | nebuliser
569
beta 2 agonists: mechanism
bind to B2 receptor which causes smooth muscle relaxation and bronchodilation B@R's found in the smooth muscle of the bronchi, GI tract, uterus and blood vessels
570
beta 2 agonists: types
short acting | long acting- take longer to act but last longer
571
beta 2 agonists: adverse effects
hypokalaemia tremor palpitations
572
corticosteroids: examples
prednisolone methylprednisolone dexamethasone
573
corticosteroids: mechanisms
supress multiple inflammatory genes | leads to reduced inflammation
574
corticosteroids: adverse effects
osteoporosis increased risk of infection weight gain

phase 2a clinical (8 decks)

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