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Respiratory Flashcards

1
Q

What is an ABG?

A

Measures blood gas tension values of arterial PO2 and PCO2 and blood’s pH

Arterial O2 saturation can be determined

Requires a small volume of blood be drawn from radial artery with syringe and thin needle

Sometimes femoral artery or arterial catheter

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2
Q

What are the indications for an ABG?

A
  • Respiratory failure
  • Identification of acid-base disorders
  • Any severe illness which may lead to a metabolic acidosis: cardiac/liver/renal/multiorgan failure, hyperglycaemic states in DM, sepsis, burns, poisons/toxins
  • Ventilated patients
  • Sleep studies
  • Severely unwell patients - affects prognosis
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3
Q

What are the possible complications of an ABG?

A
  • Local haematoma
  • Arterial vasospasm
  • Arterial occlusion
  • Air or thrombus embolism
  • LA anaphylactic reaction
  • Infection at puncture site
  • Needle stick injury to healthcare professional
  • Vessel laceration
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4
Q

What is aspergillus lung disease?

A

Lung disease associated with Aspergillus fungal infection

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5
Q

Summarise the epidemiology of aspergillus lung disease

A

Uncommon

Mainly occurs in elderly and immunocompromised

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6
Q

Explain the aetiology of aspergillus lung disease

A

Inhalation of Aspergillus spores can produce 3 different clinical pictures:
1. Aspergilloma - growth of an A. fumigates mycetoma ball in pre-existing lung cavity (eg post-TB, old infarct or abscess)

  1. Allergic bronchopulmonary aspergillosis (ABPA) - colonisation of airways by Aspergillus –> IgE/G-mediated immune responses; occurs in asthmatics; release of proteolytic enzymes, mycotoxins and antibodies –> airway damage + central bronchiectasis
  2. Invasive aspergillosis - invasion of aspergillus into lung tissue and fungal dissemination in immunosuppressed patients
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7
Q

What are the risk factors for aspergillus lung disease?

A

Asthma
CF
Elderly
Immunocompromised

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8
Q

What are the presenting symptoms of aspergillus lung disease?

A

Aspergilloma:
Asymptomatic
Haemoptysis - potentially massive

ABPA:
Difficult to control asthma
Recurrent episodes of pneumonia w wheeze, cough, fever, and malaise

Invasive aspergillosis:
Dyspnoea
Rapid deterioration
Septic picture

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9
Q

What are the signs O/E of aspergillus lung disease?

A 
Tracheal deviation (only w v large aspergillomas)
Dullness in affected lung
Reduced breath sounds
Wheeze (in ABPA)
Cyanosis (in invasive aspergillosis)
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10
Q

How is aspergillus lung disease investigated?

A

Aspergilloma:

  1. CXR - upper zone round mass w crescent of air around
  2. CT/MRI if CXR unclear

ABPA:

  1. Immediate skin test reactivity to Aspergillus antigens
  2. Eosinophilia
  3. Raised total serum IgE
  4. Raised specific serum IgE and IgG to A. fumigatus
  5. CXR
  6. CT
  7. Lung function tests

Invasive aspergillosis:

  1. Culture/histo or bronchoalveolar lavage fluid/sputum - Aspergillus
  2. Chest CT - nodules surrounded by ground-glass appearance (halo sign)
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11
Q

What does a CXR of ABPA show?

A

Transient patchy shadows
Collapse
Distended mucous-filled bronchi

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12
Q

What does a CT of ABPA show?

A

Lung infiltrates

Central bronchiectasis

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13
Q

What do lung function tests in ABPA show?

A

Reversible airflow limitation

Reduced lung volumes/gas transfer

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14
Q

What does a CXR of aspergilloma show?

A

Round mass with a crescent of air around it in upper zones

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15
Q

What does a chest CT of invasive aspergillosis show?

A

Nodules surrounded by ground-glass appearance (halo sign)

Due to haemorrhage into tissue surrounding fungal invasion

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16
Q

What is asthma?

A

Chronic inflammatory airway disease characterised by variable reversible airway obstruction, airway hyper-responsiveness and bronchial inflammation

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17
Q

Summarise the epidemiology of asthma

A

10% of children
5% of adults
Increasing prevalence

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18
Q

Explain the aetiology of asthma

A

Genetic factors:
FHx
Atopy

Environmental factors:
House dust mites
Pollen
Pets
Cigarette smoke
Viral RTIs
Aspergillus fumigatus spores
Occupational allergens
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19
Q

What are the presenting symptoms of asthma?

A

Recurrent episodes
Wheeze
SOB
Cough (worse in morning and at night)

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20
Q

What are the signs O/E of asthma?

A 
General inspection:
May be normal
Nasal polyposis
Tachypnoea
Use of accessory muscles
Prolonged expiratory phase
Hyper-inflated chest

Auscultation:
Wheeze (polyphonic)

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21
Q

What are the precipitating factors of asthma?

A 
Cold
Viral infection
Drugs - B blockers, NSAIDs
Exercise
Emotions
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22
Q

How is asthma investigated?

A
  1. FEV1/FVC ratio <80% of predicted
  2. FEV1 <80% of predicted
  3. Reduced peak expiratory flow rate
  4. CXR - normal or hyper-inflated
  5. FBC - normal or raised eosinophils and/or neutrophilia
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23
Q

What are the possible complications of asthma?

A

Exacerbations - asthma attacks
Airway remodelling
Oral candidiasis, dysphonia, and oesophageal candidiasis secondary to ICS use

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24
Q

What is bronchiectasis?

A

Lung airway disease characterised by chronic bronchial dilation, impaired mucociliary clearance and frequent bacterial infections

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25
Q

Summarise the epidemiology of bronchiectasis

A

Most often arises initially in childhood
Incidence has decreased with use of ABx
1/1000 per year

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26
Q

Explain the aetiology of bronchiectasis

A

Chronic lung inflammation –> fibrosis + permananet dilation of bronchi –> mucus pooling –> predisposes to further cycles of infection, damage, and fibrosis of bronchial walls

Causes:
Idiopathic (50%)
Post-infections - eg pneumonia, whooping cough, TB
Host-defence defects - eg Kartagener’s syndrome, CF
Obstruction of bronchi - eg foreign body, enlarged LNs
GORD
Inflammatory disorders - eg RA

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27
Q

What are the presenting symptoms of bronchiectasis?

A

Productive cough w purulent sputum or haemoptysis
Breathlessness
Chest pain
Malaise
Fever
Weight loss
Symptoms usually begin after acute respiratory illness

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28
Q

What are the signs O/E of bronchiectasis?

A

Clubbing
Coarse crepitations (usually at lung bases) that shift with coughing
Wheeze

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29
Q

How is bronchiectasis investigated?

A

Sputum:
Culture and sensitivity

CXR:
Dilated bronchi - tramline shadows (parallel lines from hilum to diaphragm)
Fibrosis
Atelectasis
Pneumonic consolidations
May be normal

High-res CT:
Best diagnostic method
Dilated bronchi w thickened walls

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30
Q

How is bronchiectasis managed?

A

Conservative:
Maintain hydration
Flu vaccination
Physiotherapy - enable sputum and mucus clearance

Medical:
Acute exacerbation - 2 IV ABx which cover Pseudomonas aeruginosa
Prophylactic ABx w >3 exacerbations/yr
ICS eg fluticasone - to reduce inflammation and sputum volume
Bronchodilators

Surgical:
Bronchial artery embolisation - if life-threatening haemoptysis
Localised resection
Lung/heart-lung transplantation

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31
Q

What are the possible complications of bronchiectasis?

A 
Life-threatening haemoptysis
Persistent infections
Empyema
Respiratory failure
Cor pulmonale
Multi-organ abscesses
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32
Q

What is the prognosis of bronchiectasis?

A

Most patients continue to have symptoms after 10 years

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33
Q

Which organisms commonly cause bronchiectasis?

A 
Pseudomonas aeruginosa
Haemophilus influenzae
Staphylococcus aureus	
Streptococcus pneumoniae
Klebsiella
Mycobacteria
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34
Q

What is extrinsic allergic alveolitis?

A

Interstitial inflammatory disease of the distal gas-exchanging parts of the lung

AKA hypersensitivity pneumonitis

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35
Q

Summarise the epidemiology of extrinsic allergic alveolitis

A

Uncommon
2% of occupational lung disease
50% of reported cases affect farm workers
Geographical variation

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36
Q

Explain the aetiology of extrinsic allergic alveolitis

A

Inhalation of antigenic dusts induce a hypersensitivity response in susceptible individuals

Antigenic dusts include microbes and animal proteins

Eg
Farmer’s Lung - mouldy hay containing thermophilic actinomycetes
Pigeon Fancier’s Lung - blood on bird feathers and excreta
Maltworker’s Lung - barley/maltings containing Aspergillus clavatus

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37
Q

What are the risk factors for extrinsic allergic alveolitis?

A

Smoking
Viral infection
Exposure to avian protein/mould/bacterial antigen
Exposure todiisocyanate
Exposure to acid anhydride antigen
Exposure to metal-working fluid
Nitrofurantoin, methotrexate, roxithomycin, rituximab
Herbal supplements with ayurvedic medicine

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38
Q

What are the presenting symptoms of extrinsic allergic alveolitis?

A 
Dyspnoea
Non-productive/productive cough
Fever/chills
Malaise
Weight loss/anorexia
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39
Q

What are the signs O/E of extrinsic allergic alveolitis?

A

Acute:
Rapid shallow breathing
Pyrexia
Inspiratory crepitations

Chronic:
Fine inspiratory crepitations
Clubbing

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40
Q

How is extrinsic allergic alveolitis investigated?

A
  1. Bloods
    FBC - neutrophilia, lymphopenia
    ABG - reduced PO2 + PCO2
  2. Serology
    - IgG to fungal/avian antigens
  3. CXR
    - often normal in acute episodes
    - fibrosis in chronic
  4. High-rest CT thorax
    - patchy ‘ground glass’ shadowing and nodules
  5. Lung function tests
    - restrictive defect (low FEV1, low FVC)
    - preserved or increased FEV1:FVC
    - reduced TLC
  6. Bronchoalveolar lavage
    - increased cellularity
    - biopsy
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41
Q

What is idiopathic pulmonary fibrosis?

A

Inflammatory condition of the lung resulting in fibrosis of the alveoli and interstitium

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42
Q

Summarise the epidemiology of idiopathic pulmonary fibrosis

A

Rare
6/100,000
More common in males

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43
Q

Explain the aetiology of idiopathic pulmonary fibrosis

A

Genetically predisposed host (e.g. surfactant protein mutations); recurrent alveolar damage results in cytokine release, activating fibroblasts, differentiating into myofibroblasts and increased collagen synthesis

Drugs can produce similar illnesses (bleomycin, methotrexate, amiodarone)

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44
Q

What are the risk factors for idiopathic pulmonary fibrosis?

A

Smoking
Occupational exposure to metal or wood
Chronic microaspiration
Animal and vegetable dusts

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45
Q

What are the presenting symptoms of idiopathic pulmonary fibrosis?

A

Gradual-onset, progressive SOB on exertion
Dry cough
No wheeze
Symptoms may be preceded by viral-type illness

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46
Q

What are the signs O/E of idiopathic pulmonary fibrosis?

A

Clubbing
Bibasal fine late inspiratory crackles
Signs of RHF in advanced disease

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47
Q

How is idiopathic pulmonary fibrosis investigated?

A

Bloods:
ABG - normal early, PO2 decreases w exercise, normal PCO2, rises in late disease
ANA/RF - 1/3 pts +ve

CXR:
Normal at presentation
Early disease - ground glass shadowing
Later disease - reticulonodular shadowing, signs of cor pulmonale, honeycombing

High-res CT:
More sensitive in early disease than CXR - ground- glass

Lung function tests:
Restrictive features - reduced FEV1 and FVC, w preserved or increased FEV1:FVC
Decreased lung volumes
Decreased lung compliance
Decreased TLC

Lung biopsy - gold standard for diagnosis

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48
Q

What is obstructive sleep apnoea?

A

A disease characterised by recurrent prolapse of the pharyngeal airway and apnoea (cessation of airflow > 10s) during sleep, followed by arousal from sleep

AKA Pickwickian Syndrome

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49
Q

Summarise the epidemiology of obstructive sleep apnoea

A

Common
5-20% of men > 35 years
2-5% of women > 35 years
Prevalence increases with age

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50
Q

Explain the aetiology of obstructive sleep apnoea

A

Occurs due to narrowing of the upper airways because of the collapse of soft tissues of the pharynx

Due to decreased tone of pharyngeal dilators during sleep

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51
Q

What are the risk factors for obstructive sleep apnoea?

A 
Weight gain
Smoking
Alcohol
Sedative use
Enlarged tonsils and adenoids in children
Macroglossia
Marfan's syndrome
Craniofacial abnormalities
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52
Q

What are the presenting symptoms of obstructive sleep apnoea?

A 
Excessive daytime sleepiness
Unrefreshing or restless sleep
Morning headaches
Dry mouth
Difficulty concentration
Irritability and mood changes
Partner reporting snoring, nocturnal apnoeic episodes or nocturnal choking
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53
Q

What are the signs O/E of obstructive sleep apnoea?

A 
Large tongue
Enlarged tonsils
Long or thick uvula
Retognathia (pulled back jaws)
Neck circumference > 42 in males/40 in females
Obesity
Hypertension
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54
Q

How is obstructive sleep apnoea investigated?

A

Sleep study - monitor airflow, respiratory effort, pulse oximetry and HR

Bloods - TFTs, ABG

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55
Q

What is pneumoconicoses?

A

Fibrosing interstitial lung disease

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56
Q

What are the risk factors for pneumoconicoses?

A

Occupational exposure to silica, coal, beryllium

High cumulative dose of inhaled silica or coal

Cigarette smoking

Chronic beryllium disease: glutamic acid at position 69 of the HLA-DP1 beta chain

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57
Q

What is presenting symptoms of pneumoconicoses?

A 
Insidious onset SOB
Dyspnoea on exertion
Dry cough
Black sputum (melanoptysis)
Pleuritic chest pain
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58
Q

What are the signs O/E of pneumoconicoses?

A

Normal chest exam

Silicosis: decreased breath sounds, signs of RHF

Asbestosis:
Bi-basal, inspiratory crepitations
Clubbing
Signs of pleural effusion or RHF (cor pulmonale)

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59
Q

How is pneumoconicoses investigated?

A
  1. CXR
    Simple: micronodular mottling
    Complicated: nodular opacities in upper zones, micronodular shadowing, eggshell calcification of hilar LNs (characteristic of silicosis), bilateral lower zone reticulonodular shadowing and pleural plaques (in asbestosis)
  2. CT scan - fibrotic changes
  3. Bronchoscopy
  4. Lung function tests - restrictive pattern (reduced FEV1 and FVC)
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60
Q

What is sarcoidosis?

A

A chronic gramulomatous disorder of unknown aetiology, commonly affecting the lungs, skin, and eyes.

Characterised by accumulation of lymphocytes and macrophages and the formation of non-caseating granulomas in the lungs and other organs.

61
Q

What are the risk factors for sarcoidosis?

A

Age 20-40 years
FHx sarcoidosis
Scandinavian origin

62
Q

What are the presenting symptoms of sarcoidosis?

A 
Cough
Dyspnoea
Chronic fatigue
Arthralgia
Wheeze
Rhonchi - bronchospasm
Photophobia
Red painful eye
Blurred vision
63
Q

What are the signs O/E of sarcoidosis?

A

Lymphadenopathy

Red eye

64
Q

How is sarcoidosis investigated?

A
  1. CXR
    Hilar and/or paratracheal adenopathy with upper lobe predominant, bilateral infiltrates; pleural effusions (rare) and egg shell calcifications (very rare)
2. Bloods
FBC: anaemia, leukopenia
Serum urea: elevated
Creatinine: elevated
Liver enzymes: elevated
Serum Ca: elevated
  1. Lung function tests
    Restrictive/obstructive/mixed pattern
  2. ECG - conduction defects
  3. Purified protein derivative of tuberculin (PPD) - negative
65
Q

What is tuberculosis?

A

Granulomatous disease caused by Mycobacterium tuberculosis

66
Q

Summarise the epidemiology of tuberculosis

A

Annual mortality = 3 million (95% in developing countries)

Annual UK incidence = 6000

Asian immigrants are highest risk group in UK

67
Q

What are the presenting symptoms of tuberculosis?

A 
Primary TB:
Mostly asymptomatic
Fever
Malaise
Cough
Wheeze
Erythema nodosum
Phlyctenular conjunctivitus
Miliary TB:
Fever
Weight loss
Meningitis
Yellow caseous tubercles spread to other organs

Post-primary TB:
Fever/night sweats
Malaise

68
Q

What are the risk factors for tuberculosis?

A 
Exposure to infection
Born in Asia, Latin America, Africa
HIV infection
Immunosuppressive medicines: systemic CS, TNF-alpha antagonists
Silicosis 30x risk
Apical fibrosis
69
Q

Explain the aetiology of tuberculosis

A

Infection by Mycobacterium tuberculosis (IC organism)

Survives after being phagocytosed by macrophages

70
Q

What are the signs and symptoms of primary TB?

A 
Mostly asymptomatic
Fever
Malaise
Cough
Wheeze
Erythema nodosum
Phlyctenular conjunctivitus
71
Q

What are the signs and symptoms of miliary TB?

A

Fever
Weight loss
Meningitis
Yellow caseous tubercles spread to other organs

72
Q

How is tuberculosis investigated?

A
  1. CXR: abnormal typical for TB; abnormal atypical for TB; or normal
  2. Sputum acid-fast bacilli smear: positive for acid-fast bacilli
  3. Sputum culture: positive; no growth; or other mycobacteria
  4. FBC: raised WBC, low Hb
  5. Nucleic acid amplification tests: +ve for M tuberculosis
73
Q

What are the signs of symptoms of post-primary TB?

A 
Fever
Night sweats
Malaise
Weight loss
Breathlessness
Cough
Sputum
Haemoptysis
Pleuritic chest pain
Signs of pleural effusion
Collapse
Consolidation
Fibrosis
74
Q

What causes miliary TB?

A

Haematogenous dissemination of TB

75
Q

What causes post-primary TB?

A

Reinfection or reactivation of TB

76
Q

What is primary TB?

A

Initial infection may be pulmonary or, more rarely, gastrointestinal

77
Q

What are the gastrointestinal signs and symptoms of TB?

A 
Subacute obstruction
Change in bowel habit
Weight loss
Peritonitis
Ascites
78
Q

What are the gastrointestinal signs and symptoms of TB?

A 
Subacute obstruction
Change in bowel habit
Weight loss
Peritonitis
Ascites
79
Q

What is pneumonia?

A

Infection of distal lung parenchyma

80
Q

Summarise the epidemiology of pneumonia

A

5-11/1000

Community-acquired pneumonia is responsible for > 60,000 deaths per year in UK

81
Q

What are the risk factors for pneumonia?

A 
Age
Smoking
Alcohol
Pre-existing lung disease
Immunodeficiency
Contact with patients with pneumonia
82
Q

What are the presenting symptoms of pneumonia?

A 
Fever
Rigors
Sweating
Malaise
Cough
Sputum
Breathlessness
Pleuritic chest pain
Confusion
83
Q

What are the signs O/E of pneumonia?

A 
Pyrexia
Respiratory distress
Tachypnoea
Tachycardia
Hypotension
Cyanosis
Decreased chest expansion
Dull to percuss over affected area
Increased tactile vocal fremitus over affected area
Bronchial breathing over affected area
Coarse crepitations on affected side
84
Q

How is pneumonia investigated?

A 
1. Bloods
FBC - raised WCC
U+Es
LFTs
Culture
ABG - assess pulmonary function
Film - Mycoplasma causes red cell agglutination
  1. CXR
    Lobar or patchy shadowing
    Pleural efusion
    Note: Klebsiella often affect upper lobes
    May detect complications, eg lung abscess
  2. Sputum/pleural fluid - MC&S
  3. Urine - Penumococcus and Legionella antigens
  4. Atypical viral serology
  5. Bronchoscopy and bronchoalveolar lavage - if Penumocystis carinii pneumonia suspected, or if pneumonia fails to resolve
85
Q

How is pneumonia managed?

A
  1. Assess severity using BTS guidelines
  2. Empirical ABx
    - oral amoxicillin (0 markers)
    - oral/IV amoxicillin + erythromycin (1 marker)
    - IV cefurozime/cefotaxime/co-amoxiclav + erythromycin (>1 marker)
    - add metronidazole if: aspiration, lung abscess, empyema
    - switch to appropriate antibiotic based on sensitivity
  3. Supportive treatment
    - oxygen
    - IV fluids
    - CPAP, BiPAP, ITU care for resp failure
    - surgical drainage for abscess/empyema
  4. Discharge planning
    If 2+ features of clinical instability present (high temp, tachycardia, tachypnoea, hypotension, low O2 sats) - high risk of readmission and mortality
    Consider other causes if pneumonia not resolving
86
Q

What are the possible complications of pneumonia?

A 
Pleural effusion
Epyema
Localised suppuration, eg abscess - swinging fever, persistent pneumonia, copious/foul-smelling sputum
Septic shock
ARDS
Acute renal failure
87
Q

What is the prognosis of pneumonia?

A

Most resolve with Tx within 1-3 weeks

Severe pneumonia has high mortality

88
Q

How can pneumonia be characterised?

A 
Community-acquired
Hospital-acquired/nosocomial
Aspiration
Pneumonia in the immunocompromised
Typical
Atypical (Mycoplasma, Chlamydia, Legionella)
89
Q

What are the atypical pneumonia symptoms?

A

Headache
Myalgia
Diarrhoea/abdo pain
Dry cough

90
Q

What is the CURB-65 score?

A

Used to assess severity of pneumonia

Confusion < 8 AMTS
Urea > 7 mmol/L
Respiratory rate > 30/min
Blood pressure: systolic < 90mmHg or diastolic < 60mmHg
Age > 65 years
91
Q

How can pneumonia be prevented?

A

Pneumococcal vaccine
Haemophilus influenzae type B vaccine
Given to high risk groups, eg elderly, spenectomy

92
Q

How can pneumonia be prevented?

A

Pneumococcal vaccine
Haemophilus influenzae type B vaccine
Given to high risk groups, eg elderly, splenectomy

93
Q

What is pneumothorax?

A

Air in the pleural space

94
Q

Summarise the epidemiology of pneumothorax

A

Annual incidence: 9/100,000
20-40yos
4x more common in males

95
Q

Explain the aetiology of pneumothorax

A

Spontaneous:

  • occurs in people w typically normal lungs
  • typically in tall, thin males
  • probably caused by rupture of subpleural bleb

Secondary:
- pre-existing lung disease, eg COPD, asthma, TB

Traumatic:

  • penetrating injury to chest
  • often iatrogenic, eg during jugular venous cannulation, thoracocentesis
96
Q

What are the risk factors for pneumothorax?

A 
Smoking
FHx
Tall and slender
<40yo
Recent invasive medical procedure
Chest trauma
Acute severe asthma
COPD
TB
AIDS-related Pneumocystis jirovecii infection
CF
Lymphangioleiomyomatosis
Birt-Hogg-Dube syndrome
Pulmonary Langerhans cell histiocytosis
Erdheim-Chester disease
97
Q

What are the presenting symptoms of pneumothorax?

A

May be asymptomatic if small
Sudden-onset breathlessness
Pleuritic chest pain
Distress w rapid shallow breathing in tension pneumothorax

98
Q

What are the signs O/E of pneumothorax?

A 
No signs if small
Signs of respiratory distress
Reduced expansion
Hyper-resonance to percussion
Reduced breath sounds
Tension pneumothorax:
Severe resp distress
Tachycardia
Hypotension
Cyanosis
Distended neck veins
Tracheal deviation away from side of pneumothorax
99
Q

How is pneumothorax investigated?

A

CXR:

  • dark area of film w no lung markings
  • fluid level may be seen if there is any bleeding

ABG: check for hypoxaemia

100
Q

How is pneumothorax managed?

A

Oxygen
Chest-tube thoracostomy
Immediate needle decompression (tension)
Suction

101
Q

What are the possible complications of pneumothorax?

A

Recurrent pneumothoraces

Bronchopleural fistula

102
Q

What is the prognosis of pneumothorax?

A

20% have another pneumothorax

Frequency increases w repeated pneumothoraces

103
Q

What is pulmonary embolism?

A

Occlusion of pulmonary vessels, most commonly by a thrombus that has travelled to the pulmonary vascular system from another site

104
Q

Summarise the epidemiology of pulmonary embolism

A 
Relatively common (especially in hospitalised patients)
Occur in 10-20% of patients with confirmed proximal DVT
105
Q

Explain the aetiology of pulmonary embolism

A

Thrombus
95% arise from DVT in lower limbs
Rarely arises in right atrium (in AF patients)

Other causes of embolus:
Amniotic fluid
Air
Fat
Tumour
Mycotic
106
Q

What are the risk factors for pulmonary embolism?

A 
Surgical patients
Immobility
Obesity
OCP
Heart failure
Malignancy
107
Q

What are the presenting symptoms of pulmonary embolism?

A

Depends on site and size of embolus

Small - may be asymptomatic

Moderate - sudden onset SOB, cough, haemoptysis, pleuritic chest pain

Large (or proximal) - as above + severe central pleuritic chest pain, shock, collapse, acute RHF, sudden death

Multiple small recurrent - symptoms of pulmonary HTN

108
Q

What are the signs O/E of pulmonary embolism?

A

Small - often no clinical signs, may be some tachycardia and tachypnoea

Moderate - tachypnoea, tachycardia, pleural rub, low O2 sats despite supplementation

Massive - shock, cyanosis, signs of right heart strain (raised JVP, left parasternal heave, accentuated S2)

Multiple recurrent PE - signs of pulmonary HTN, signs of RHF

109
Q

How is pulmonary embolism investigated?

A

Well’s Score used to determine best investigation for PE

Low probability (Wells 4 or less) - use D-dimer

High probability (Wells>4) - requires imaging (CTPA)

Also:
Bloods - ABG, thrombophilia screen
ECG - normal, tachycardia, right axis deviation or RBBB, S1Q3T3 pattern
CXR - often normal but helps exclude other diagnoses
VQ scan - shows areas of mismatch –> infarcted lung
Doppler US of lower limb - VTE
Echocardiography - may show right heart strain

110
Q

How is pulmonary embolism managed?

A

Primary prevention:
Compression stockings
Heparin prophylaxis for those at risk
Good mobilisation and adequate hydration

If haemodynamically stable:
O2
Anticoagulation w heparin or LMWH
Switch over to oral warfarin for at least 3 months
Maintain INR 2-3
Analgesia

If haemodynamically unstable (massive PE):
Resuscitate
O2
IV fluids
Thrombolysis with tPA considered if cardiac arrest imminent

Surgical/radiological:
Embolectomy
IVC filtres - sometimes used for recurrent PEs despite adequate anticoagulation/when CI

111
Q

What are the possible complications of pulmonary embolism?

A

Death
Pulmonary infarction
Pulmonary hypertension
Right heart failure

112
Q

What is the prognosis of pulmonary embolism?

A

30% mortality in those left untreated
8% mortality with treatment
Increased risk of future thromboembolic disease

113
Q

What is lung cancer?

A

Primary malignant neoplasm of the lung

Small cell - 20%
Non-small cell - 80%

114
Q

Summarise the epidemiology of lung cancer

A

Most common fatal cancer in the west
18% of cancer mortality worldwide
3x more common in males

115
Q

What are the risk factors for lung cancer?

A

Smoking
Asbestos exposure
Other occupational exposure: polycyclic hydrocarbons, nickel, radon
Atmospheric pollution

116
Q

What are the presenting symptoms of lung cancer?

A

May be asymptomatic

Primary:
Cough, haemoptysis, chest pain, recurrent pneumonia

Local invasion:
Brachial plexus invasion –> shoulder/arm pain
Left recurrent laryngeal nerve invasion –> hoarse voice and bovine cough
Dysphagia
Arrhytmias
Horner’s syndrome

Metastatic disease/paraneoplastic phenomenon:
Weight loss
Fatigue
Fractures
Bone pain
117
Q

What are the presenting symptoms of lung cancer?

A

May be asymptomatic

Primary:
Cough, haemoptysis, chest pain, recurrent pneumonia

Local invasion:
Brachial plexus invasion –> shoulder/arm pain
Left recurrent laryngeal nerve invasion –> hoarse voice and bovine cough
Dysphagia
Arrhytmias
Horner’s syndrome

Metastatic disease/paraneoplastic phenomenon:
Weight loss
Fatigue
Fractures
Bone pain
118
Q

What are the signs O/E of lung cancer?

A

May be NO SIGNS
Fixed monophonic wheeze (single obstruction)
Signs of lobar collapse or pleural effusion
Signs of metastases - Virchow’s node

119
Q

What is COPD?

A

Chronic, progressive lung disorder characterised by airflow obstruction that is not fully reversible, with the following:

Chronic bronchitis - chronic cough and sputum production on most days for at least 3 months per year over 2 consecutive years

Emphysema - pathological diagnosis of permanent destructive enlargement of air spaces distal to terminal bronchioles

120
Q

Summarise the epidemiology of COPD

A

Very common - 8% prevalence
Presents in middle age or later
More common in males
Increasingly common in females

121
Q

What are the risk factors for COPD?

A

Smoking

122
Q

What are the presenting symptoms of COPD?

A 
Chronic cough
Sputum production
SOB
Some wheeze
Reduced exercise tolerance
123
Q

What are the signs O/E of COPD?

A

General inspection:
Tar staining
Cyanosis
Barrel chest

Palpation:
Reduced expansion

Percussion:
Hyper-resonance

Auscultation:
Reduced air mvmt
Wheezing
Coarse crackles (hair-like)

Other:
Signs of RHF

124
Q

How is COPD investigated?

A

Spirometry and lung function tests:
Obstructive picture - reduced PEFR, FEV1:FVC, increased lung volumes, decreased CO gas transfer coefficient

CXR:
May appear normal
Hyperinflation (>6 anterior ribs, flattened diaphragm)
Reduced peripheral lung markings
Elongated cardiac silhouette

Bloods:
FBC - increased Hb and hct due to secondary polycythaemia

ABG: hypoxia, normal/raised PCO2

ECG and echocardiogram: check for cor pulmonale

Sputum and blood cultures: useful in acute infective exacerbations

A1 antitrypsin levels (deficiency)

125
Q

What are the possible complications of COPD?

A 
Acute respiratory failure
Infections
Pulmonary hypertension
Right heart failure
Pneumothorax - secondary to bullae rupture
Secondary polycythaemia
126
Q

What is the prognosis of COPD?

A

High morbidity
3-year surivial of 90% if < 60 years, FEV1 > 50% predicted
3-year survival of 75% if > 60 years, FEV1: 40-49% predicted

127
Q

What is asbestosis?

A

Diffuse interstitial fibrosis of the lung as a consequence of exposure to asbestos fibres

128
Q

Explain the aetiology of asbestosis

A

Inhalation of asbestos fibres
A fibrous silicate, a naturally occurring mineral

The more asbestos inhaled, the greater the risk of developing asbestosis

129
Q

What are the risk factors for asbestosis?

A

Cumulative dose of inhaled asbestos

Smoking (reduces ability of lung to clear asbestos fibres)

130
Q

What are the presenting symptoms of asbestosis?

A

SOB on exertion

Dry, non-productive cough

131
Q

What are the signs O/E of asbestosis?

A

Dyspnoea
Crackles - initially at bases
Clubbing in advanced disease

132
Q

How is asbestosis investigated?

A
  1. CXR: PA and lateral
    Lower zone linear interstitial fibrosis; progressively involves entire lung; pleural thickening
  2. Lung function tests
    Restrictive changes
    May have obstructive picture - esp if Hx of asbestos exposure and smoking
133
Q

What is mesothelioma?

A

An aggressive epithelial neoplasm arising from the lining of the lung, abdomen, pericardium, or tunica vaginalis

134
Q

Summarise the epidemiology of mesothelioma

A

More common in men and white people
Typically occurs in 60-90yos
In UK, incidence increasing rapidly since 60s
Country-to-country variation due to disparities in asbestos use and regulation

135
Q

Explain the aetiology of mesothelioma

A

Asbestos exposure
Dose-response relationship
Latency period between exposure and development of malignancy = 20-40 years

Also:
Radiotherapy
Genetic - BAP1 mutation, SV-40

136
Q

What are the risk factors of mesothelioma?

A

Asbestos exposure
60-85 yo due to latency period (20-40 years)
Male
FHx

137
Q

What are the presenting symptoms of mesothelioma?

A

Increasing SOB
Chest pain
Dry, non-productive cough
Constitutional: fever, fatigue, sweats, weight loss

138
Q

What are the signs O/E of mesothelioma?

A

Laboured breathing
Diminished breath sounds (due to effusion, trapped lung, bronchial obstruction)
Dullness to percussion (effusion)

139
Q

How is mesothelioma investigated?

A
  1. CXR
    - unilateral pleural effusion
    - irregular pleural thickening
    - reduced lung volumes
    - parenchymal changes, eg lower zone linear interstitial fibrosis
  2. Chest CT
    - pleural thickening and/or discrete pleural plaques
    - pleural and/or pericardial effusions
    - enlarged hilar and/or mediastinal LNs
    - chest wall invasion and/or spread along needle tracts
  3. Thoracentesis
    - exudate
    - malignant cells in pleural fluid
140
Q

How is asthma managed?

A
  1. SABA - salbutamol
  2. SABA + ICS - salbutamol + beclomethasone
  3. LABA + ICS - salmeterol + beclomethasone
  4. Trials - theophylline, oral beta-agonists, oral leukotriene receptor agonists (Montelukast)
  5. Oral CS
141
Q

How is an acute asthma attack investigated?

A

PEF

Moderate = 50-75%
Acute-severe = 33-50
Life-threatening = <33
Near fatal = raised pCO2

142
Q

How is an acute asthma attack managed?

A
  1. Basic obs - HR, SpO2
  2. Measure and record PEF
  3. O2 saturation and maintain SpO2 at 94-98%
  4. ABG
  5. Serum K and glucose

Repeat ABG if PaO2 <8kPa, unless SpO2 >92%; or initial PaCO2 is normal or raised; or if patient deteriorates

143
Q

How is chronic COPD managed?

A
  1. SABA or SAMA - salbutamol or ipratroprium bromide - MILD
  2. Add LABA or LAMA - salmeterol or tiotropium - MODERATE
  3. LAMA + LABA or LABA + ICS - symbicort (budesonide (ICS) and formoterol (LABA)) - SEVERE
  4. LAMA + LABA + ICS - VERY SEVERE
Also:
Smoking cessation
Annual flu vaccine
Pneumoccocal vaccine
Long term O2 therapy
Lung volume reduction surgery
144
Q

What are the long-term O2 therapy guidelines?

A

pO2 < 7.3kPa and one of the following:

  • secondary polycythaemia
  • nocturnal hypoxaemia
  • peripheral oedema
  • pulmonary HTN
145
Q

How do you manage an infective exacerbation of asthma?

A
  1. O2
  2. Neb salbutamol 5mg/Neb ipratropium bromide 0.5mg
  3. Oral prednisolone 40-50mg + IV hydrocortisone 100mg
  4. IV magnesium sulphate + SENIOR HELP
  5. IV aminophylline
  6. ITU + intubation
146
Q

How do you manage an infective exacerbation of COPD?

A
  1. (Blue Venturi) 24% O2
  2. Neb salbutamol 5mg, neb ipratropium bromide 0.5mg
  3. Oral prednisolone 40-50mg, IV hydrocortisone 200mg
  4. IV amoxicillin
  5. 500mg IV aminophylline
  6. BiPAP (NIV)
147
Q

How is the severity of COPD classified?

A 
FEV1 %
> 80% - mild
50-79% - moderate
30-49% - severe
< 30% very severe
148
Q

What are the respiratory causes of clubbing?

A

Malignancy
Empyema lung abscess
ILD
CF

Y3 (20 decks)

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