Respiratory Flashcards
What is Chronic obstructive pulmonary disease?
A chronic lung condition characterised by breathlessness due to poorly reversible and progressive airflow obstruction
What is the most common patient that presents with COPD?
Middle-aged to elderly adult smokers
What causes COPD?
Smoking, previous workplace exposure to dusts and fumes, alpha1-antitrypsin deficiency.
What is the pathology behind COPD?
Inflammation and scarring of small bronchioles causes airflow obstruction.
Describe the pathophysiology of COPD
Lungs hyper inflated with thick mucus in the airways and dilated terminal airspaces.
Emphysema and finely pigmented macrophages in resp. bronchioles
How does COPD present?
Sudden onset of exertion breathlessness on a background of prolonged cough and sputum production.
Dyspnoea, wheeze, cyanosis, cor pulmonale
How is COPD diagnosed?
CXR: hyperinflation, large central PAs CT: bronchial wall thickening, scarring ECG: cor pulmonale ABG: low PaO2 with hypercapnia Spirometry: obstructive
How is COPD managed?
Encourage exercise, diet advice. Smoking cessation. Mucolytics - help chronic productive cough.
SABA/SAMA
FEV1 > 50% LABA
FEV1 <50% LABA plus inhaled corticosteroid in combined inhaler
What can acute COPD exacerbations be triggered by?
Viral/bacterial infections. Common medical emergency in Winter
How do acute COPD exacerbations present?
Increasing cough, breathlessness, wheeze, decreased exercise capacity
How are acute COPD exacerbations managed?
Look for a cause, treat the reversible - controlled oxygen therapy, nebulised bronchodilators (salbutamol), antibiotics
What is asthma?
A chronic inflammatory disorder of large airways characterised by recurrent episodes of reversible airway narrowing
What is the pathology behind asthma?
Atopic individuals respond to allergens - produce large amounts of IgE which bind to the surface of mast cells.
Re-exposure causes degranulation of mast cells, which stimulate airway inflammation and bronchospasm
Inflammation results in hypersensitive reactions
How does asthma present?
Intermittent episodes of breathlessness, wheeze, and chest tightness
Cough, particularly at night
Acid reflux
What are the precipitants of asthma?
Cold air, exercise, emotion, allergens, infection, smoking, NSAIDs, beta blockers
How is asthma diagnosed?
Spirometry, trial on asthma treatment and if successful continue minimum effective dose.
Acute attack: PEF, sputum culture
Chronic: spirometry - obstructive defect, CXR - hyperinflation
How is chronic asthma managed (general)?
Help to quit smoking, avoid precipitants, weight loss, check inhaler technique
How is chronic asthma managed pharmacologically?
Step 1: short-acting inhaled beta2-agonist
Step 2: standard-dose inhaled steroid e.g. beclametasone
Step 3: add long-acting beta2-agonist
Step 4: consider trials of beclametasone/ oral theophylline/ oral leukotriene receptor antagonist
Step 5: add regular oral prednisolone
How does a severe asthma attack present, how is it diagnosed and how is managed?
Acute breathlessness and wheeze
ABG if <92% ox sats
Supplement oxygen, salbumatol 5mg nebuliser with oxygen
What is respiratory failure?
Defined as arterial PO2 <8kPa
What is the difference between type 1 and 2 respiratory failure?
Type 1 - normal or low pCO2
Type 2 - raised pCO2
What can cause type 1 respiratory failure?
Severe pneumonia, pulmonary embolism, acute asthma, pulmonary fibrosis, acute LVF
What can cause type 2 respiratory failure?
COPD, neuromuscular disorders impairing ventilation e.g. myasthenia gravis, reduced respiratory drive e.g. sedative drugs
How are lung carcinomas classified?
Histologically - small cell, non-small cell
NSCLC: Adenocarcinoma, squamous cell carcinoma
How do lung carcinomas present?
Progressive breathlessness, cough, chest pain, hoarseness or loss of voice, weight loss, recurrent pneumonia
How can lung carcinomas metastases present?
Abdominal pain, bony pain, neurological symptoms
What are some extrapulmonary manifestations of bronchial cancer?
Ectopic secretion of ACTH, ADH, PTH Cerebellar degeneration Anaemia Dermatomyositis Clubbing
How are lung carcinomas diagnosed?
CXR: lung collapse, hilar enlargement
Cytology: sputum and pleural fluid
Fine needle aspiration
Lung function tests
What are the risk factors for lung carcinomas?
Cigarette smoking, passive smoking, asbestos, radiation, arsenic
How are non-small cell lung carcinomas managed?
Lobectomy if medically fit and aim is curative intent
Radical radiotherapy
How are small cell lung carcinomas managed?
Chemo, radiotherapy. Consider surgery
SVC stent + radiotherapy and dexamethasone
Analgesia, steroids, anti-emetics
Name 2 benign lung tumours and how they are treated.
Bronchial adenoma
Hamartoma
Surgical excision
What are mesotheliomas?
Malignant tumours arising in the pleura from mesothelial cells
What causes mesotheliomas?
Inhaled asbestos fibres become permanently entrapped in the lung. These become coated with iron, forming asbestos bodies
How do mesotheliomas present?
Breathlessness, chest pain, profound weight loss and malaise
Signs of mets: hepatomegaly, bone pain, abdominal pain
How are mesotheliomas diagnosed?
CXR: pleural thickening/ effusion. Bloody pleural fluid
Diagnosis made on histology (often post-mortem)
How are mesotheliomas managed?
Pemetrexed + cisplatin chemotherapy can improve survival
What is a pulmonary embolism?
Occlusion of a pulmonary artery by an embolic thrombus
What are the risk factors for pulmonary embolisms?
Immobility, recent surgery, malignancy, pregnancy - all cause DVTs which embolise
What causes pulmonary embolisms?
A fragment of a detached thrombus from DVT embolisms via the right side of the heart into the pulmonary arterial circulation and lodges in a pulmonary artery
How do pulmonary embolisms present?
Major PA - instant death - sudden rise in pulmonary arterial pressure, acute RVF, cardiac arrest
Medium PA - breathlessness (V/Q mismatch)
Small PA - breathlessness, chest pain, dizziness
How are pulmonary embolisms diagnosed?
D-dimers, ABG: may show layered PaO2 and PaCO2
Imaging: CXR may be normal
ECG: normal/ tachycardic
How are pulmonary embolisms managed?
Oxygen if hypoxic Morphine IV with anti-emetic if patient is in pain LMW heparin DOAC/ warfarin Thrombolyse massive PE (IV alteplase)
How can pulmonary embolisms be prevented?
Give heparin to all immobile patients
Stop HRT and the combined contraceptive pill pre-op
What organism causes TB?
Mycobacterium tuberculosis - an acid-fast rod-shaped bacillus
How is TB transmitted?
Via inhalation of aerosol droplets containing the bacterium.
What is latent TB?
Infection without disease due to persistent immune system containment.
Positive skin/blood testing shows evidence of infection but patient is asymptomatic and non-infectious
What are the risk factors for the reactivation of TB?
New infection, HIV, organ transplantation, immunosuppression, silicosis, illicit drug use, malnutrition
What patient groups does active disease TB tend to occur in?
Elderly, malnourished, diabetic, immunosuppressed, alcoholic
How does TB present?
Chronic pneumonia with persistent cough, fever, night sweats, weight loss and loss of appetite, malaise, clubbing
How does extra pulmonary TB present?
Meningitis, lymphadenopathy, GU symptoms, bone/joint pain
How is TB diagnosed?
Acid-fast bacilli may be seen in sputum, pleural fluid
CXR: fibronodular opacities in upper lobe
Nucleic acid amplification test
Culture (takes 12 weeks but is definitive)
How is TB managed?
Antibiotics - rifampicin, isoniazid, pyrazinamide, ethambutol
What is pneumonia?
An infection of the lung parenchyma caused by bacterial organisms
What are the classifications of pneumonia?
Community-acquired, hospital-acquired, aspiration, immunosuppression
What organisms can cause community-acquired pneumonia?
Streptococcus pneumonias, haemophilus influenzae, legionella pneumophila
What organisms can cause hospital-acquired pneumonia?
Gram negative enterobacteria or Staph. aureus
Also Klebsiella, pseudomonas
What organisms can cause aspiration pneumonia?
Mixed aerobic and anaerobic bacteria
What organisms can cause immunosuppression pneumonia?
Strep. pneumoniae, H.influenzae, Staph. aureus, M. pneumonias
What is the pathology behind pneumonia?
Bacterial organisms overcome the defences of the lung and establish infection within the alveoli
How does pneumonia present?
Productive cough, breathlessness, chest pain, fever, rigors, haemoptysis, cyanosis, confusion, tachypnoea, hypotension
How is pneumonia diagnosed?
CXR: lobar/ multilobar infiltrates, pleural effusion
Sputum: microscopy and culture
Urine: check for Legionella/ Pneumococcal urinary antigens
How is the severity of pneumonia assessed?
CURB-65, 1 point for each:
Confusion, urea >7mmol/L, resp rate >30/min, BP <90 systolic, age 65+
How is pneumonia managed?
Hypoxia - oxygen, dehydration - IV fluids, analgesia for chest pain
Antibiotics; CURB 0-1 = oral amoxicillin/ doxycycline
CURB 2 = oral amoxicillin + clarithromycin/ doxycycline
CURB 3 = co-amoxiclav + clarithomycin
What are the complications of pneumonia?
Respiratory failure, hypotension, atrial fibrillation, pleural effusion, empyema, lung abscess, septicaemia
What infections can occur in the upper respiratory tract?
Common cold (acute coryza), sinusitis, rhinitis, acute pharyngitis, croup, influenza
What causes the common cold and how is it spread?
Rhinovirus infection, spread by droplets and close personal contact
What is sinusitis and what causes it?
Infection of paranasal sinuses, caused by strep pneumonia or H. influenzae
What are the symptoms of sinusitis and how is it treated?
Frontal headache, facial pain and tenderness, nasal discharge
Broad-spectrum antibiotics, topical corticosteroids
What is rhinitis and what are the different types?
Sneezing attacks, nasal discharge or blockage occurring >1h most days
Limited period of the year - seasonal
Throughout whole year - perennial/ persistent rhinitis
What is seasonal rhinitis?
Hayfever - allergy to grass and tree pollen, and a variety of mould spores which grow on cultivated plants. Nasal symptoms - itching of eyes and soft palate
How is rhinitis diagnosed and managed?
Clinical, skin-prick testing to identify causal agents.
Avoid allergens, antihistamines, decongestants
How does acute pharyngitis present and how is it treated?
Sore throat and fever
Penicillin IV four times a day for 10 days
What is croup?
Acute laryngotracheobronchitis
Inflammatory oedema involving larynx = hoarse voice, barking cough and stridor
What is the big problem with influenza A?
It has the capacity to undergo antigenic shift and major changes in the H and N antigens are associated with pandemic infections
What is seasonal influenzae?
Acute viral infection of lungs and airways. Seasonal epidemics peak during the winter in temperate countries
How does influenza present?
Fever, dry cough, sore throat, coryzal symptoms, headache, malaise, myalgia, conjunctivitis, eye pain, photophobia
How is influenza diagnosed?
Clinical: acute onset + cough + fever
Viral culture of clinical samples
How is influenza managed?
Symptomatic treatment e.g. paracetamol
Antivirals only if high risk - chronic disease, immunosuppression, pregnancy
How is influenza prevented?
Post-exposure prophylaxis
Annual vaccine in UK
What are interstitial lung diseases?
Conditions characterised by chronic inflammation and/or progressive interstitial fibrosis.
Idiopathic pulmonary fibrosis, sarcoidosis
What is idiopathic pulmonary fibrosis?
An idiopathic interstitial pneumonia limited to the lung and associated with a histological appearance of usual interstitial pneumonia (UIP)
How does idiopathic pulmonary fibrosis present?
Progressive breathlessness, non-productive cough, malaise, weight loss, arthralgia, cyanosis, finger clubbing
How is idiopathic pulmonary fibrosis diagnosed?
ABG: low PaO2, raised PaCO2
Imaging: decreased lung volume, honeycomb lung
Spirometry: restrictive
Lung biopsy
How is idiopathic pulmonary fibrosis managed?
Supportive: oxygen, pulmonary rehab, opiates
Clinical trials/ transplant
What is sarcoidosis?
A multi system disease of unknown cause in which tissues are infiltrated by granulomas
How does sarcoidosis present?
Dry cough, progressive dyspnoea, lower exercise tolerance
How is sarcoidosis diagnosed?
24hr urine: raised calcium
Tissue biopsy: diagnostic
How is sarcoidosis managed?
Bed rest, NSAIDs
Corticosteroids
What is bronchiectasis?
An abnormal permanent dilation of bronchi accompanied by inflammation in their walls and in adjacent lung parenchyma
What causes bronchiectasis?
Congenital: Young’s syndrome, primary ciliary dyskinesia
Post-infection: measles, pertussis, pneumonia, TB, HIV
Other: bronchial obstruction
What is the pathology behind bronchiectasis?
The result of weakening in bronchial walls caused by recurrent inflammation. Scarring in the adjacent lung parenchyma places traction on the weakened bronchi, causing them to permanently dilate
What are the main organisms that cause bronchiectasis?
H. influenzae, Strep. pneumonias, Staph. Aureus, Pseudomonas aeruginosa
How does bronchiectasis present?
Persistent cough, copious purulent sputum, intermittent haemoptysis, finger clubbing, wheeze
How is bronchiectasis diagnosed?
Sputum culture
CXR: thickened bronchial walls
Bronchoscopy: local site of haemoptysis
How is bronchiectasis managed?
Airway clearance techniques + mucolytics
Chest physiotherapy
Antibiotics, bronchodilators, surgery (haemoptysis)
What is cystic fibrosis?
An inherited disorder caused by a mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene
What causes cystic fibrosis?
Deletion on chromosome 7q leads to abnormal CFTR protein
How does cystic fibrosis present?
Neonate: failure to thrive
Cough, wheeze, recurrent infection, pancreatic insufficiency, gallstones, cirrhosis
How is cystic fibrosis diagnosed?
Bacteriology: cough swab, sputum culture
CXR: hyperinflation
Abdo US: fatty liver, cirrhosis, chronic pancreatitis
Spirometry: obstructive defect
How is cystic fibrosis managed?
Chest physiotherapy e.g. postural drainage, airways clearance techniques
Bronchodilators
Pancreatic enzyme replacement
What is pleural effusion?
An accumulation of excess fluid within the pleural space
What are the different fluids that can enter the pleural space?
Blood - haemothorax
Pus - empyema
Chyle (lymph with fat) - chylothorax
Blood + air - haemopneumothorax
What can cause a pleural effusion?
Increased pulmonary venous congestion - LVF, inflammation of the pleura - pneumonia, PE, infiltration of the pleura - malignancy
How do pleural effusions present?
Asymptomatic, breathlessness, pleuritic chest pain
How are pleural effusions diagnosed?
Visible on CXR
Diagnostic aspiration
Pleural biopsy
How are pleural effusions managed?
Drainage of the effusion
Pleurodesis
Surgery
What is a pneumothorax?
The presence of air within the pleural space
What causes a spontaneous pneumothorax?
The rupture of small delicate apical blebs of lung tissue which result from stretching of the lungs. Air leaks out of the damaged lung into the pleural space, and the lung collapses
How does a pneumothorax present?
Unilateral pleuritic chest pain, breathlessness
How is a pneumothorax diagnosed?
Radiology: air in the pleural space
Expiratory film: area devoid of lung markings
How is a pneumothorax managed?
Chest drain, aspiration
What is a tension pneumothorax?
Medical emergency - air drawn into the pleural space with each inspiration has no route of escape, the mediastinum is pushed over into the contralateral hemithorax, kinking and compressing the great veins. Cardiorespiratory arrest will occur.
What are the signs of a pneumothorax?
Respiratory distress, tachycardia, hypotension, distended neck veins
How is a pneumothorax managed?
Remove the air with a large-bore needle
What is pulmonary hypertension?
A mean pulmonary artery pressure >25mmHg at rest or >30mmHg during exercise
What is the pathology behind pulmonary hypertension?
Chronic hypoxia and obliterative pulmonary fibrosis both lead to the development of raised pressure in the pulmonary arterial circulation
How does pulmonary hypertension present?
Primary - exertion dyspnoea, fatigue
Secondary - increasing breathlessness
How is pulmonary hypertension diagnosed?
CXR: enlarged proximal pulmonary arteries
ECG: RVH
How is pulmonary hypertension managed?
Oxygen, warfarin, diuretics for oedema, oral CCBs, treat underlying cause
What is hypersensitivity pneumonitis?
(extrinsic allergic alveolitis) - an interstitial lung disease caused by an immunologic reaction to inhaled antigens
What can cause hypersensitivity pneumonitis?
Thermophilic bacteria, fungi, Avian proteins
How does hypersensitivity pneumonitis present?
Acute: Breathlessness, cough, fever, rigors, myalgia, dry cough
Chronic: finger clubbing, increasing dyspnoea, weight loss, exertion dyspnoea
How is hypersensitivity pneumonitis diagnosed?
CT: middle to upper lobe interstitial opacities and small nodules
CXR, Lung function tests
How is hypersensitivity pneumonitis managed?
Identify causative agent and avoid exposure.
Acute - remove allergen
Chronic - allergen avoidance, long term steroids
What is coal worker’s pneumoconiosis (CWP)?
Common dust disease which results from inhalation of coal dust particles.
How does coal worker’s pneumoconiosis present and how is it managed?
Asymptomatic but coexisting chronic bronchitis is common
Avoid exposure to coal dust, treat chronic bronchitis
What is progressive massive fibrosis?
Due to progression of CWP, which causes progressive dyspnoea, fibrosis and cor pulmonale
What is silicosis and how is it managed?
Caused by inhalation of silica particles, which are very fibrogenic.
Progressive dyspnoea
Avoid exposure to silica
What is asbestosis and how does it present?
Caused by inhalation of asbestos fibres.
Progressive dyspnoea, clubbing
Who suffers from byssinosis?
Cotton mill workers
What is Goodpasture’s syndrome?
Anti-glomerular basement membrane disease
Auto-antibodies to type IV collagen (present in GBMs)
What is Wegener’s granulomatosis?
A multisystem disorder of unknown cause characterised by necrotising granulomatous inflammation and vasculitis of small and medium vessels
