respiratory Flashcards
1
Q
what are the symptoms of COPD and all related conditions?
A
cough, sputum, dyspnoea and wheeze
2
Q
what are the signs of COPD and all related conditions?
A
tachypnoea, use of accessory muscles of respiratory at rest, decreased expansion, cyanosis, cor pulmonale
3
Q
how can COPD be diagnosed?
A
- FBC- raised PCV
- CXR- hyperinflation, flat hemidiaphragms, large pulmonary arteries
- ABG- hypercapnia and decrease in PaO2
- lung function tst- FEV1:FVC ratio less than 70%
4
Q
how would a patent with COPD be treated?
A
- smoking cessation
- bronchodilators
- short-acting antimuscarinic- ipratropium
- inhaled tiotropium bromide
- short acting beta2 agonist- salbutamol
5
Q
how is severe COPD treated?
A
combination of long acting beta2 agonist and corticosteroids- e.g. budesonide and formoterol
6
Q
how are acute exacerbations managed?
A
- Controlled O2 given to maintain SaO2 >88-92% and PaO2 > 8kPa without increasing PaCO2- Low concentration oxygen given via Venturi mask, to prevent removing their hypoxic drive
- Bronchodilators (salbutamol) given along with oral prednisolone
- Abx given if there’s a history of more purulent sputum production or with CXR changes
7
Q
what is Chronic bronchitis?
A
Chronic bronchitis is a clinical term defined as cough and sputum for 3 months in 2 consecutive years
8
Q
how is chronic bronchitis characterised histologically
A
It is histologically characterised by a non-specific chronic inflammatory infiltrate within the walls of bronchi and bronchioles. This can be associated with the formation of bronchial-associated lymphoid tissue (BALT)
9
Q
what is emphysema?
A
Emphysema is defined as an abnormal enlargement of alveolar airspaces distal to the terminal bronchiole. there is a loss of elastic recoil, resulting in expiratory airflow limitation and air trapping
10
Q
what is asthma?
A
Asthma is defined as hyper-reactivity of the bronchial tree with paroxysmal narrowing of the small airways
11
Q
what is asthma characterised by?
A
characterised by reversible small-airway obstruction characterised by bronchospasm, airway inflammation and oedema
12
Q
how is asthma categorised?
A
A. Extrinsic (atopic)- allergens identified by positive skin prick reactions to common inhaled allergens such as dust mites, pollens and fungi
B. Intrinsic- usually occurs in middle age and no definite external cause can be identified
13
Q
what environmental influences can cause asthma?
A
early childhood exposure to allergens, maternal smoking and childhood infections
14
Q
describe the pathophysiology of asthma
A
During the inflammation process, mast cells and eosinophils migrate into the bronchial wall. Remodelling then occurs- the airway smooth muscle undergoes hyperplasia and hypertrophy. This results in a thickened airway wall, which damages the epithelium as ciliated columnar cells are lost into the lumen. Due to this loss of some epithelial cells, the epithelium undergoes metaplasia and increased the number of mucous secreting goblet cells
15
Q
how do patients with asthma present clinically?
A
symptoms- dyspnoea, wheeze, cough, sputum
signs- tachypnoea, hyper inflated chest, air entry reduction, widespread polyphonic wheeze
16
Q
how is asthma diagnosed?
A
Asthma can be diagnosed by the patient demonstrating a variable of greater than 15% airway limitation by measurement of PEF or FEV1. Skin prick tests can also be used to identify triggers and CXR is used during an acute attack to rule out pneumonia or pneumothorax
17
Q
what is the first line of treatment in a patient with asthma?
A
lifestyle control- smoking cessation ,avoiding precipitants, checking inhaler technique
18
Q
what is the pharmacological treatment pathway for asthma set out by the British Thoracic society guidelines?
A
1 .B2- agonist PRN- salbutamol
2. Inhaled steroid- beclomethasone
3/ Long acting B2-agonist- salmeterol
4. High doses of beclomethasome or modified-release theophylline
5. Oral prednisolone and refer to asthma clinic
19
Q
what are the local effects of a primary lung tumour?
A
haemoptysis, bronchial obstruction, breathlessness, consolidation
tumour can also infiltrate the visceral pleura leading to pleural effusion
20
Q
what are the most common sites that primary lung tumours will metastasise to?
A
lymph nodes, liver, pleura, adrenal glands, bone and brain
21
Q
what are the risk factors of a pulmonary embolism?
A
recent surgery, thrombophilia, leg fracture, prolonged bed rest, malignancy, pregnancy or a previous PE
22
Q
what symptoms will a patient with a PE present with?
A
acute breathlessness, pleuritic chest pain, haemoptysis and syncope
23
Q
what clinical signs can be detected in a patient with a PE?
A
pyrexia, cyanosis, tachypnoea, tachycardia, hypotension, pleural rub and pleural effusion
24
Q
what will the results of an ABG be in a patient with a PE?
A
low PaO2, Low PaCO2
25
How would you manage a patient with a PE?
- Give oxygen if hypoxic
- morphine and LMWH
- if patient is still harm-dynamically unstable, consider thrombolysis or vasopressors
26
what causes the initial infection in TB?
mycobacterium tuberculosis
27
what are the systemic symptoms of TB?
- Pulmonary TB- cough, sputum, malaise, weight loss, sweats, pleurisy, haemoptysis
- Miliary TB- CXR shows nodular opacities
- Genitourinary TB- dysuria, frequency, back pain, haematuria
- Bone TB- vertebral collapse and Pott’s vertebra
- Skin TB- jelly-like nodules on face and neck
- Peritoneal TB- abdo pain, GI upset
28
how can TB be diagnosed?
- CXR- consolidation, cavitation, calcification and fibrosis
- sputum sample testing
- PCR for mycobacterium tuberculosis
29
what is the treatment plan for a patient with TB?
6- month regimen- take rifampicin, isoniazid, pyrazinamide and ethambutol for 2 months then taking rifampicin and isoniazid for a further 4 months
30
which groups of people are most at risk of pneumonia?
infants, elderly, immunocompromised, nursing home residents and alcoholics
31
what are some differential diagnoses of asthma?
pulmonary oedema, COPD, large airway obstruction due to a tumour, SVC obstruction, pneumothorax, PE, bronchiectasis or obliterative bronchiolitis
32
what conditions can increase a patients' chance of developing pneumonia?
COPD, diabetes and congestive heart disease
33
what are the symptoms of pneumonia?
fever, sweats, rigors, cough, sputum, SOB, pleuritic chest pain that is worse on deep breathing, systemic features and rash
34
what clinical signs can be seen in a patient with pneumonia?
raised heart and respiratory rate, low BP, fever and dehydration
35
in pneumonia, lung consolidation can occur- what can be heard on percussion and auscultation in patients with this?
dull to percussion, decreased air entry, bronchial breath sounds, crackles and increased vocal resonance
36
what investigations can be done on a patient with pneumonia?
- CXR- multi lobar suggestive of S. pneumonia/ s.aureus, multiple abcesses or pneumatoceles of S. aureus
- Full blood count
- Biochemistry- urea, electrolytes and liver function tests
- C- reactive protein
- pulse oximetry
- Microbiological tests
37
what is the CURB65?
used to predict the mortality of patients with pneumonia.
1 point is given for each of the criteria met:
-Confusion
-Urea ≥7mmol/L
-Respiratory rate≥ 30/min
-Blood pressure; low systolic < 90mm/Hg or diastolic ≤60mm/Hg
- Age ≥ 65
0=0.7%,
1 =2.1%,
3= 9.2%
4-5=15-40%
38
what is the treatment of mild community-acquired pneumonia?
oral amoxicillin/ erythromycin/ clarithromycin.
| if no response in 48 hours- CXR and review treatment
39
what is the treatment of severe community- acquired pneumonia?
- IV cefuroxime and IV clarithromycin
| - flucloxacillin and sodium fusidate added if gram positive cocci are present
40
what viruses most commonly cause upper respiratory tract infections (URI's)?
include rhinovirus, infleunza A, coronavirus, adenovirus, parainfluenza virus and respiratory syncytial viruses
41
what are the main complication of URI's?
sinusitis, pharyngitis, otitis media, bronchitis and pneumonia
42
what virus causes the common cold (acute coryza)?
rhinovirus infection
43
what are the symptoms of acute coryza?
- Malaise
- Slight pyrexia
- Sore throat
- Watery nasal discharge – becomes mucopurulent after a few days
44
what is sinusitis?
infection of the paranasal sinuses
45
what organisms most commonly cause sinusitis?
Strep pneumonia or H influenzae
46
what are the symptoms of sinusitis?
Frontal headache
Facial pain and tenderness
Nasal discharge
47
how is sinusitis treated?
- Broad-spectrum abx (e.g. co-amoxiclav)
- Topical corticosteroids – e.g. fluticasone propionate nasal spray to reduce local mucosal swelling
- Steam inhalations
48
what is rhinitis?
•Sneezing attacks, nasal discharge or blockage occurring for more than 1h for most days:
oFor a limited period of the year (seasonal rhinitis)- e.g. hay fever
o Throughout the whole year (perennial or persistent rhinitis)
49
how is perennial rhinitis categorised?
allergic
| non-allergic- triggered by cold air, smoke and perfume
50
how is rhinitis managed?
- Avoid allergens
- Antihistamines e.g. cetirizine
- Decongestant topical steroids e.g. beclometasone spray twice daily
51
what virus must commonly causes acute pharyngitis?
adenoviruses
52
if acute pharyngitis is more persistent what does this imply?
bacterial infection caused by
| haemolytic Strep, Haemophilus influenza, staphylococcus aureus
53
what are the symptoms of acute pharyngitis?
sore throat and fever
54
how is acute pharyngitis treated?
penicillin V four times a day for 10d
| if allergic to penicillin use erythromycin
55
what is acute laryngotracheobronchitis (croup)?
infection with a parainfluenza virus or measles virus
56
when doe symptoms of acute laryngotracheobronchitis most commonly present?
when the patient is under 3 years old
57
what are the symptoms of acute laryngotracheobronchitis?
hoarse voice, barking cough (croup) and stridor
symptoms caused by inflammatory oedema
58
how is acute laryngotracheobronchitis treated?
O2 therapy
oral/ IM corticosteroids
nebuliser adrenaline
59
what is the pathophysiology of influenza?
* Two main forms of the influenza virus = A and B
* Surface of virion is coated with haemagglutinin (H) and neuraminidase (N) – both are necessary for attachment to the host respiratory epithelium
* Human immunity develops against the H and N antigens
* Influenza A has the capacity to undergo antigenic ‘shift’ and major changes in the H and N antigens are associated with pandemic infections
* Minor antigenic ‘drifts’ are associated with less severe epidemics
60
what are the clinical features a patient with influenza would present with?
- Incubation periods = 1-3d
- Abrupt onset of fever
- Generalized aching of limbs
- Severe headache
- Sore throat and dry cough
- May last several weeks
- Flu symptoms are a lot worse than common cold
- Fever, generalized aching and dry cough = flu
- Runny and stuffy nose = common cold
61
how is influenza diagnosed?
- serology shows rise in antibody titre
| - virus demonstrated in throat and nasal secretions
62
how is influenza managed?
- Symptomatic treatment – paracetamol, bed rest, maintenance of fluid intake
- Antibiotics to prevent secondary infection
- In a pandemic, neuraminidase inhibitors (e.g. zanamivir and oseltamivir) are offered to all with suspicious symptoms
63
what is the main complication of influenza?
pneumonia
64
what is pulmonary fibrosis?
Pulmonary fibrosis is a type of idiopathic interstitial pneumonia. Patients typically present late in their 60’s and are commonly male
65
what are the symptoms of pulmonary fibrosis?
a dry cough, exertional dyspnoea, malaise, weight loss and arthralgia
66
what are the clinical signs seen in a patient with pulmonary fibrosis?
cyanosis, finger clubbing and fine-end inspiratory crepitations
67
how is pulmonary fibrosis diagnosed?
- bloods- raised CRP and ANA
- ABG- low PAo2
- CXR- decreased lung volume and bilateral lower zone reticulonodular shadows- honeycomb appearance
68
how is pulmonary fibrosis treated?
oxygen therapy, pulmonary rehabilitation, opiates and supportive care of the patient
69
what is sarcoidosis?
Sarcoidosis is a multisystem granulomatous disorder, of which the cause is unknown
70
how is sarcoidosis diagnosed?
usually found incidentally on a CXR- bloods showing raised ESR, LFT and serum ACE can confirm diagnosis.
an US can also be done which will show hepatosplenomegaly
71
what are the symptoms of sarcoidosis?
fever, erythema nodosum and bilateral hilar lymphadenopathy
72
what are the non-pulmonary signs of sarcoidosis?
hepatosplenomegaly, uveitis, glaucoma and conjunctivitis
73
how is sarcoidosis treated?
- most recover spontaneously
| - bed rest and NSAIDs
74
what is bronchiectasis?
Bronchiectasis is chronic inflammation of the bronchi and bronchioles leading to permanent dilatation and thinning of these airway
75
what organisms most commonly cause bronchiectasis?
h. influenzae, strep. Pneumoniae, staph. Aureus and pseudomonas aeruginosa
76
apart from viral causes what else can cause bronchiectasis?
cystic fibrosis, bronchial obstruction, allergic bronchopulmonary aspergillosis and rheumatoid arthritis
77
what signs and symptoms will a patient with bronchiectasis present with?
symptoms- persistent cough and sputum
| signs- finger clubbing, coarse inspiratory crepitations and wheeze
78
how is bronchiectasis diagnosed?
through either a sputum culture, a CXR showing cystic shadows and thickened bronchial walls, spirometry showing an obstructive pattern or bronchoscopy to locate the site of haemoptysis
79
how can a patient with bronchiectasis be diagnosed?
- airway clearance techniques
| - antibiotics
80
what is cystic fibrosis?
Cystic fibrosis is an autosomal recessive condition caused by mutations in a gene on chromosome 7
81
what is the pathophysiology of cystic fibrosis?
a deletive mutation results in a reduction in the numbers of a type of chloride channel found in the lungs, pancreas, GI and reproductive tract. This results in decreased chloride secretion and increased sodium absorption across the airway epithelium, therefore the mucous produced is very viscous
82
what symptoms will a neonate with cystic fibrosis present with?
failure to thrive and rectal prolapse
83
what systemic symptoms will children and adults with cystic fibrosis present with?
- Respiratory- wheeze, cough, infections, bronchiectasis, pneumothorax, haemoptysis, respiratory failure and cor pulmonale
- GI- pancreatic insufficiency, gallstones and cirrhosis
- Other- male infertility, osteoporosis, arthritis, vasculitis, sinusitis
- General signs such as cyanosis, finger clubbing and bilateral coarse crackles.
84
how is cystic fibrosis diagnosed?
- genetic testic
- sweat test- greater Cl concentration that Na
- sputum culture
- CXR- lung hyperinflation and bronchiectasis
- spirometry- obstructive defect
85
how can cystic fibrosis be treated?
chest physiotherapy, postural drainage, antibiotics for infective exacerbations and mucolytics.
Systems also need to be treated- e.g. pancreatic enzyme replacement
86
what is pulmonary hypertension associated with?
development of cor pulmonale- right ventricular hypertrophy
87
what is the aetiology of pulmonary hypertension?
- Pre-capillary affects- pulmonary emboli, left-to-right shunts (cardiac septal defects) and primary pulmonary hypertension (unknown cause)
- Capillary defects- severe reduction in the vascular bed- e.g. in emphysema
- Post-capillary defects- high pressure in the pulmonary venous system resulting in secondary back pressure into the arterial tree. Examples of this include mitral stenosis and left ventricular failure
88
how does a patient with pulmonary hypertension present clinically?
symptoms- exertional dyspnoea, lethargy, fatigue, peripheral oedema and abdominal pain due to hepatic congestion
signs- loud pulmonary second sound, elevated JVP, hepatomegaly and a pulsatile liver
89
how is pulmonary hypertension diagnosed?
depends on the cause- a CXR can show enlarged proximal pulmonary arteries, and ECG will indicate RVH and cor pulmonale and an echocardiogram will show right ventricular dilation/ hypertrophy
90
what are the treatment options for a patient with pulmonary hypertension?
oxygen therapy, warfarin, diuretics to treat the oedema, oral CCBs as well as treating the underyling cause
91
what is the aetiology of Hypersensitivity pneumonitis/ extrinsic allergic alveolitits?
This is caused by inhalation of allergens provoking a hypersensitivity reaction- e.g. farmers lung, bird-fanciers lung, malt workers lung
92
what is the key difference between acute and chronic Hypersensitivity pneumonitis/ extrinsic allergic alveolitits?
acute- alveoli are infiltrated with acute inflammatory cells
| chronic- granuloma formation and obliterative broncholitis
93
how would a patient with Hypersensitivity pneumonitis/ extrinsic allergic alveolitits present clinically?
acute- fever, rigors, myalgia, dry cough
| chronic- weight loss, exertion dyspnoea, type 1 respiratory failure and cor pulmonale
94
how are both acute and chronic hypersensitivity pneumonitis/ extrinsic allergic alveolitits diagnosed?
acute- bloods indicating neutrophilia, CXR and lung function tests showing a reversible restrictive effect
chronic- persistent changes on lung function tests
95
how are acute and chronic hypersensitivity pneumonitis/ extrinsic allergic alveolitits treated?
acute- oral prednisolone
chronic- avoiding exposure and long-term steroids
96
what is the pathophysiology of coal-workers pneumoconiosis?
- Coal is ingested by alveolar macrophages
- These aggregate around bronchioles
- Anthracosis- presence of coal dust pigment in the lung
97
what is silicosis?
fibres can be toxic to macrophages- this leads to their death with the release of proteolytic enzymes
98
how does a patient with silicosis present clinically?
present with progressive dyspnoea and a CXR showing military or nodular pattern
99
what can asbestos disease lead to?
diffuse pulmonary fibrosis, diffuse pleural fibrosis, lung cancer or mesothelioma
100
how do patients with asbestos disease present clinically?
progressive dyspnoea, clubbing, pleural plaques and fine end-inspiratory crackles
101
what are examples of extrinsic allergic alveolitis?
bird fancier’s lung or farmer’s lung, type 3 hypersensitivity
102
what is byssinosis?
common in cotton mill workers
| -Symptoms begin once returning to work (Monday) and get better during working week
103
what are the symptoms of byssinosis?
tight chest, cough and breathlessness
104
what is berylliosis?
beryllium is a copper alloy used in the aerospace industry. Beryllium is inhaled and causes a systemic illness that causes progressive dyspnoea and pulmonary fibrosis
105
what is good pastures syndrome?
a pulmonary-renal syndrome that presents with acute glomerulonephritis and lung symptoms
106
what is the aetiology of good-pastures syndrome?
Caused by anti-glomerular basement membrane antibodies – bind kidney basement membrane and alveolar membrane
107
how is good pastures syndrome diagnosed?
* CXR – infiltrates due to pulmonary haemorrhage, often in lower zones
* Kidney biopsy – crescenteric glomerulonephritis
108
how is good pastures treated?
Vigorous immunosuppressive treatment and plasma pharesis
109
what is Wegener's granulomatosis?
This is a multisystem disorder of unkown cause that is characterised by necrotizing granulomatous inflammation and vasculitis of small and medium vessels. This affects the respiratory tract, lungs and kidneys.
110
how does Wegener's granulomatosis present clinically?
presents with nasal obstruction, glomerulonephritis, haematuria, cough, haemoptysis, pleuritis, peripheral neuropathy, arthritis and ocular involvement (keratitis, conjunctivitis, scleritis, episcleritis and uveitis)
111
how is Wegener's granulomatosis diagnosed?
- bloods- raised cANCA, ESR, CRP
- urinanalysis- proteinuria and haematuria
- CXR- nodules
- CT- diffuse alveolar haemorrhage
112
how is Wegener's granulomatosis treated?
azathioprine and methotrexate
113
what is a mesothelioma?
A mesothelioma is a tumour of the mesothelial cells that occurs in the pleura
114
what is the most common cause of mesothelioma?
asbestos
115
how does a patient with mesothelioma present clinically?
chest pain, dyspnoea, weight loss, finger clubbing, recurrent pleural effusions, lymphadenopathy, hepatomegaly and abdominal pain
116
how is a mesothelioma diagnosed?
- CXR- pleural thickening
117
how is a mesothelioma treated?
pemetrexed and cisplatin chemotherapy
118
what conditions does COPD cover?
chronic bronchitis and emphysema
119
what is the genetic influence on asthma?
IL-4 gene cluster on chromosome 5, controls production of IL-3, -4, -5 and -13 – affects mast and eosinophil cell development and longevity, and IgE production
120
what is a pneumothorax?
Air in the pleural space leading to partial or complete collapse of the lung
121
what is a tension pneumothorax?
Tension pneumothorax (rare, unless px is on mechanical ventilation) – pleural tear acts as a one way valve – air passes through during inspiration but is unable to exit during expiration
122
what is the aetiology of a pneumothorax?
- spontaneous
- chest trauma
- asthma
- COPD
- TB
- pneumonia
123
how does a pneumothorax present clinically?
symptoms- sudden onset pleuritic chest pain
| signs- reduced expansion, diminished breath sounds on affected side
124
how is a pneumothorax diagnosed?
CXR
125
how is a pneumothorax treated?
- if due to trauma- chest drain
| - aspiration
126
how is a tension pneumothorax treated?
- large-bore needle inserted into 2nd intercostal space in mid-clavicular line
127
what is the pathophysiology of a tension pneumothorax?
* Air drawn into pleural space with each inspiration has no escape during expiration
* Mediastinum is pushed over into the contralateral hemithorax – kinking and compressing the great veins
* Unless air is rapidly removed, cardiorespiratory arrest will occur
128
how are primary bronchial tumours staged?
TNM staging
Primary tumour
• T0 = none evident
• T1 = <3cm in lobar, or more distal airway
• T2 = >3cm and >2cm distal to carina or any size if pleural involvement or obstructive pneumonitis extending to hilum
• T3 = involves chest wall, diaphragm, mediastinal pleura, pericardium or <2cm from carina. T >7cm and nodules in same lobe.
• T4 = involves mediastinum, heart, great vessels, trachea, oesophagus vertebral body, carina, malignant effusion, or nodules in another lobe
Regional nodes
• N0 = none involved
• N1 = peribronchial and/or ipsilateral hilum
• N2 = ipsilateral mediastinum or subcarinal
• N3 = contralateral mediastinum or hilum, scalene or supraclavicular
Distant Metastases
• M0 = none
• M1 = (a) nodule in other lung, pleural lesions or malignant effusion; (b) distant metastases present
129
what are some risk factors of bronchial carcinoma?
- smoking
- asbestos
- chromium
- arsenic
- radiation
130
how does a bronchial carcinoma present clinically?
- cough
- haemoptysis
- dyspnoea
- chest pain
- lethargy
- anorexia
- weight loss
131
how can a bronchial carcinoma be diagnosed?
- CXR- consolidation, pleural effusions, lung collapse
- fine needle biopsy
- CT- tumour staging
132
how is bronchiectasis managed?
- airway clearance techniques alongside antibiotics
| - nebulised salbutamol can also be used if patient is asthmatic
