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Year 4 Semester 2 > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Risk factors for asthma?

A

Genetic: atrophy
Environmental: allergens, hygiene hypothesis, adult-onset (e.g. occupational)

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2
Q

What is asthma?

A

Allergic airway problem causing airway obstruction

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3
Q

Asthma triggers?

A 
Aeroallergens
Exercise
Anxiety/stress
Temperature changes
Cigarette smoke
Foods, additives
Occupational agents e.g. isocyanates
Drugs: NSAIDs, b-blockers
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4
Q

What predisposes people to getting asthma?

A

Airway hyperresponsiveness
Sensitisation to house dust mites
Female
Smoking at age 21

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5
Q

Obstructive spirometry?

A

FEV1 < 80% predicted
FVC normal/low
FEV1/FVC < 70%

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6
Q

How to investigate asthma?

A 
Spirometry
Peak flow
Reversibility testing
Chest x-ray
Blood eosinophils
IgE
Skin prick tests
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7
Q

What is a positive reversibility test result for asthma?

A

> 400 ml improvement or symptom scores

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8
Q

How to diagnose asthma?

A

Clinical diagnosis based on presence of symptoms (dyspnoea, cough, wheeze)
Supported by evidence from investigations

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9
Q

Features supportive of an asthma diagnosis?

A 
Wheeze
Dyspnoea
Chest tightness
Especially after a trigger
Widespread wheeze on auscultation
Unexplained low FEV1 or PEF
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10
Q

Factors that don’t support an asthma diagnosis?

A

Dizziness, light-headedness, peripheral tingling -> hyperventilation
Chronic productive cough without wheeze or dyspnoea -> COPD, bronchiectasis, chronic cough syndrome
Repeatedly normal examination when symptomatic
Vocal disturbance -> vocal cord dysfunction
Symptoms only with colds -> bronchial hyper-reactivity syndrome
> 20 pack year SHx -> COPD
Cardiac disease
Normal PEF/spirometry when symptomatic

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11
Q

What to do if you suspect asthma?

A

Trial asthma treatment
If successful: continue
If not successful: assess inhaler technique and compliance
If no further improvement: consider other causes, referral

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12
Q

Non-pharmacological management of asthma?

A

Avoid triggers

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13
Q

Pharmacological management of asthma?

A 
Stepwise approach
1. Low dose ICS and SABA PRN
2. Add inhaled LABA
3. Can stop LABA if no response
    Can increase ICS dose
    Can add in a trial therapy
4. High dose ICS
    Can add in a fourth drug e.g. LAMA
    Referral
5. Daily steroid tablet
     High dose ICS
     Referral
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14
Q

Name some SABAs?

A

Salbutamol

Terbutaline

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15
Q

What treatments can you consider in severe asthma clinics?

A 
High dose ICS
Tiotropium
Immunosuppressants
Macrolide antibiotics
Biologics e.g. anti IgE (omalizumab), anti IL-5 (mepolizumab)
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16
Q

Asthma add on therapies?

A 
LABA + ICS e.g. Foster
Leukotriene receptor antagonists
Theophylline
Higher dose ICS
Oral steroids
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17
Q

What is the main cause of acute asthma exacerbations?

A

Viral URTI

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18
Q

How to manage acute asthma exacerbations?

A

ABCDE
High flow O2 -> aim for sats 94%
Salbutamol MDI + spacer or O2 driven nebuliser
Add ipratropium if no response (SAMA)
Engage critical care team if very severe
Prednisolone 40 mg for 5 days to reduce chance of recurrence

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19
Q

How to prevent acute asthma exacerbations?

A

Asthma management plan
Annual review
Identify the at risk patients

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20
Q

What is COPD?

A

Inflammatory airway problem causing chronic airway obstruction

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21
Q

Environment risk factors for COPD?

A 
Cigarette smoking
Environmental tobacco smoke
Occupation: dust, chemicals
Indoor and outdoor pollution
Infections
Socio-economic status
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22
Q

Host risk factors for COPD?

A

Genes- alpha-1 antitrypsin deficiency
Hyper-responsiveness
Poor lung growth
Increasing age

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23
Q

Pathology of COPD?

A

Inflammatory airway problem causes small airway narrowing and alveolar destruction

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24
Q

Triad of COPD pathological changes?

A

Bronchial gland enlargement
Emphysema
Bronchiolitis

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25
Q

What is chronic bronchitis?

A

Hyperplasia of goblet cells -> hypersecretion of mucus

Cough productive of sputum on most days for 3 months over 2 consecutive years

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26
Q

What is emphysema?

A

Abnormal, permanent enlargement of airspaces distal to the terminal bronchioles and destruction of their walls without obvious fibrosis

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27
Q

Types of emphysema?

A

Centrilobular emphysema: common in smokers

Pan-lobular emphysema: common in alpha-1 antitrypsin deficiency

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28
Q

COPD symptoms?

A

Dyspnoea
Chronic cough
Chronic sputum production

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29
Q

Physical examination of COPD?

A 
Tachpnoea
Accessory muscle use
Pursed lip breathing
Hyper-inflation: this makes it hard to localise the apex beat
Hoover's sign
Reduced breath sounds
Wheeze
Respiratory crackles
Central cyanosis
Flapping tremor
Peripheral oedema
Weight loss/loss of muscle mass
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30
Q

Common triggers of COPD exacerbations?

A

Bacteria
Virus
Pollutants

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31
Q

Investigations for COPD?

A

Modified MRC questionnaire (mMRC)
COPD assessment test (CAT)
Spirometry
Chest x-ray
Lung volume and diffusing capacity (severity)
Oximetry and ABG
Genetic screening if < 45 years or strong FHx

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32
Q

What is the reversibility testing result in COPD?

A

> 200 ml and 12% of pre-drug value

If > 400 ml -> think asthma

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33
Q

How to assess severity in COPD?

A

Post-bronchodilator FEV1

GOLD ABCD assessment

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34
Q

Post-bronchodilator FEV1 severity in COPD?

A 
Stage I (mild): FEV1 ≥ 80% predicted
Stage II (moderate): FEV1 50-79% predicted
Stage III (severe): FEV1 30-49% predicted
Stage IV (very severe): FEV1 < 30% predicted or < 50% with respiratory failure
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35
Q

GOLD ABCD severity assessment for COPD?

A

A: low risk, less symptoms
B: low risk, more symptoms
C: high risk, less symptoms
D: high risk, more symptoms

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36
Q

COPD management?

A

Reduce risk factors
Smoking cessation
Pulmonary rehabilitation
SABA or LABA
Bronchodilators dependent on GOLD severity
Nebuliser: consider if FEV1 < 50% post bronchodilator or very symptomatic

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37
Q

COPD drug management based on GOLD severity?

A 
A: Bronchodilator
B: LABA or LAMA
    Then LABA + LAMA
C: LAMA 
     Then LAMA + LABA OR LABA + ICS
D: LAMA OR LAMA + LABA OR LAMA + ICS
     Then LAMA + LABA + ICS
     Then Roflumilast (FEV1 < 50%) or macrolide (former      smoker)
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38
Q

COPD exacerbation management?

A 
Optimise bronchodilators
Use a nebuliser
Antibiotics
Short course of oral corticosteroids
Treat respiratory failure if present
Oxygen
Ventilation if needed
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39
Q

How to treat Type 1 respiratory failure?

A

Controlled oxygen

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40
Q

How to treat Type 2 respiratory failure?

A 
Controlled oxygen
Nebulisers
Antibiotics
Oral corticosteroids
Monitor
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41
Q

What is bronchiectasis?

A

Chronic inflammation of the bronchi and bronchioles -> permanent dilation and thinning of the airways

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42
Q

Causes of bronchiectasis?

A

Congenital: cystic fibrosis, Young’s syndrome, primary ciliary dyskinesia, Kartagener’s syndrome
Post-infective: measles, pertussis, bronchiolitis, pneumonia, TB, HIV
Other: bronchial obstruction, allergic bronchopulmonary aspergillosis, hypogamaglobulinaemia, RA, UC
Idiopathic

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43
Q

Common presentation of bronchiectasis?

A

Recurrent pulmonary infections

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44
Q

Bronchiectasis symptoms?

A

Persistent cough
Copious purulent sputum
Intermittent haemoptysis

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45
Q

Bronchiectasis signs?

A

Finger clubbing
Course inspiratory crackles
Crackles often clear after coughing
Wheeze

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46
Q

Complications of bronchiectasis?

A 
Pneumonia
Pleural effusions
Pneumothorax
Haemoptysis
Cerebral abscess
Amyloidosis
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47
Q

Investigations for bronchiectasis?

A 
Sputum culture
Chest x-ray
CT scan
Spirometry: obstructive pattern
Bronchoscopy
Serum immunoglobulin
CF sweat test
Aspegillus precipitants or skin prick test RAST and total IgE
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48
Q

Bronchiectasis signs on chest x-ray?

A

Tramline and ring shadows
Thickened bronchial walls
Cystic shadows

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49
Q

Bronchiectasis signs on CT?

A

Signet ring sign

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50
Q

Types of pulmonary TB?

A

Active infection

Latent infection

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51
Q

When is TB transmissible?

A

From a person with an active infection

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52
Q

Clinical features of TB?

A 
Low-grade fever
Anorexia
Weight loss
Malaise
Night sweats
Pleuritic pain
Clubbing (due to bronchiectasis)
Erythma nodosum
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53
Q

Clinical features of pulmonary TB?

A 
Cough: dry then productive
Pleurisy
Haemoptysis
Pleural effusion
Aspergilloma/mycetoma may form in cavities
Asymptomatic or atypical presentation
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54
Q

Investigations for active TB?

A 
Chest x-ray
Sputum acid-fast bacilli (AFB) smear
Sputum culture
FBC
Nucleic acid amplification test (NAAT)
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55
Q

Investigations for latent TB?

A

Tuberculin skin test (TST)

Interferon-gamma release test (IGRAS)

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56
Q

Treatment of active TB?

A

Notify local public health protection
NAAT for drug resistance
Antibiotics

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57
Q

What are the antibiotics used in TB?

A

Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

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58
Q

What lung diseases can Aspergillus cause?

A

Asthma
Allergic bronchopulmonary aspergillosis (ABPA)
Aspergilloma (mycetoma)
Extrinsic allergic alveolitis

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59
Q

What does ABPA stand for?

A

Allergic bronchopulmonary aspergillosis

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60
Q

What is the pathology of ABPA?

A

Type I and III hypersensitivity reactions to Aspergillus -> bronchoconstriction then permanent damage (bronchiectasis)

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61
Q

Clinical features of ABPA?

A 
Wheeze
Cough
Sputum
Mucus plugs containing fungal hyphae
Dyspnoea
Recurrent pneumonia
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62
Q

Investigations for ABPA?

A 
Chest x-ray
Sputum contains Aspergillus
Positive skin test
Aspergillus specific IgE RAST
Positive serum precipitants
Eosinophilia
Raised serum IgE
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63
Q

Management of ABPA?

A

Prednisolone
Antifungal
Bronchodilators
Bronchoscopic aspire for mucus plugs

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64
Q

What is aspergilloma?

A

A fungus ball in a pre-existing cavity e.g. from TB or sarcoidosis

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65
Q

Clinical features of aspergilloma?

A 
Usually asymptomatic
Cough
Haemoptysis
Lethargy
Weight loss
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66
Q

Investigations for aspergilloma?

A

Chest x-ray
Sputum culture
Aspergillus skin test

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67
Q

Management for aspergilloma?

A

Only if symptomatic

Surgical excision for solitary symptomatic lesions or severe haemoptysis

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68
Q

Investigations for invasive aspergillosis?

A 
Sputum culture
BAL
Biopsy -> diagnostic
Serum precipitants
Chest x-ray
Early chest CT
Serial measurements of galactomannan
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69
Q

Treatment of invasive aspergillosis?

A

Antifungals e.g. voriconazole

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70
Q

What is extrinsic allergic alveolitis?

A

Hypersensitivity reaction to inhaled fungal spores in sensitised individuals

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71
Q

Acute clinical features of extrinsic allergic alveolitis?

A 
Fever
Rigors
Myalgia
Dry cough
Dyspnoea
Fine bibasal crackles
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72
Q

Chronic clinical features of extrinsic allergic alveolitis?

A 
Finger clubbing
Increasing and exertion dyspnoea
Weight loss
Type 1 respiratory failure
Cor pulmonale
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73
Q

Investigations for extrinsic allergic alveolitis?

A 
Bloods: FBC, ESR, serum antibodies
ABG
Chest x-ray
Spirometry: restrictive disease (is reversible at first)
BAL (for chronic disease)
CT chest (for chronic disease)
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74
Q

Management of extrinsic allergic alveolitis?

A

Acute: remove allergen, oxygen, prednisolone
Chronic: allergen avoidance, long-term steroids
Can get compensation for some causes

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75
Q

Risk factors for bronchial carcinoma?

A 
Cigarette smoking
Passive smoking
Asbestos
Chromium
Arsenic
Iron oxides
Radiation
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76
Q

Types of bronchial carcinoma?

A

Small cell: 15-20%

Non-small cell: > 80%

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77
Q

Types of non-small cell lung cancer?

A

Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma

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78
Q

Pathology of small cell lung cancer?

A

Aggressive

Neuroendocrine

79
Q

Clinical features of lung cancer?

A 
Systemic:
Weight loss
Anorexia
Fatigue
Night sweats
Fever

Primary tumour:
Cough
Haemoptysis
Wheeze (monophonic)
Dyspnoea

Local invasion:
Chest pain
Dysphagia
Hoarseness
Stridor
Superior vena cava obstruction
Rib erosion
Horner's syndrome (Pancoast's tumour)

Non-metastatic extra pulmonary:
Endocrine
Neurological
Vascular
Cutaneous
Skeletal

Metastatic:
Bone
CNS/brain
Liver

Paraneoplastic:
Hypercalcaemia due to ectopic PTH or bony metastases
SIADH
Ectopic ACTH
Cerebellar syndrome
Eaton Lambert syndrome
Limbic encephalitis
Cushings syndrome
80
Q

Investigations for lung cancer?

A

Chest x-ray
CT chest and abdo
CT PET scan
Biopsy: CT guided, bronchial, liver, VATS/thorascoscopy, mediastinoscopy, EUS, resection

81
Q

How is lung cancer staged?

A

TNM staging

Tissue diagnosis: biopsy, cytology (sputum, pleural fluid)

82
Q

Common sites of lung metastases?

A 
Mediastinal/hilar lymph nodes
Peripheral lymph nodes
Pleura
Bone
Liver
Skin
Brain
Adrenal glands
83
Q

What do you need to know about a patient before making a management plan for lung cancer?

A 
ECOG performance status
Exercise tolerance
Activities of daily living
Cardiac staus
Renal or hepatic dysfunction
Co-morbidities
Other lung disease
Cognitive impairment
Fraility
84
Q

When is lung cancer potentially curable?

A

Non-small cell
N staging < N3
If the patient is otherwise well and healthy

85
Q

Management options for lung cancer?

A 
Surgery
Radiotherapy
Chemotherapy
Biologics
Palliation
86
Q

Types of surgery for lung cancer?

A

Lobectomy
Pneumonectomy
Wedge resection or segmentectomy

87
Q

When do you use surgery for lung cancer?

A

When it is possible to treat
If the patient is well enough to tolerate surgery and loss of some lung tissue
Not for: metastases, nodal spread

88
Q

What is radiotherapy for in lung cancer?

A

Does have a curable intent

89
Q

Types of radiotherapy for lung cancer

A

Radical radiotherapy: for when other factors exclude surgery
Stereoblastic ablative radiotherapy: concentrated form for small peripheral lesions away from the mediastinum and important structures

90
Q

What does chemotherapy do in lung cancer?

A

Extension of life

Improvement of quality of life

91
Q

Palliation in lung cancer?

A

Radiotherapy for distressing complications e.g. SVCO, recurrent haemoptysis, pain (chest wall invasion, skeletal metastases)

92
Q

Management for SVCO in lung cancer?

A

Dexamethasome -> reduces oedema
Anticoagulation
SVC stenting

93
Q

Which cancers commonly cause secondary lung cancer?

A 
Breast
Kidney
Uterus
Ovary
Testes
Thyroid
94
Q

What does PE stand for?

A

Pulmonary embolism

95
Q

What is pulmonary embolism?

A

A venous thromboembolic event

96
Q

Causes of pulmonary embolism?

A

Due to lower limb DVT: 80%
Right sided endocarditis
Tumours
Fat/ai/amniotic fluid emboli

97
Q

Risk factors for pulmonary embolism

A

Recent surgery: abdo, hip, knee, post-op intensive care
Obs and gynae: pregnancy, puerperium, CCP, HRT
Cardio and resp: COPD, congestive cardiac failure
Lower limb: fracture, varicose veins
Stroke/spinal cord injury
Malignancy: abdo, pelvic, advanced/metastatic, concurrent chemotherapy
Increasing age
Previous proven VTE
Immobility
Thrombotic disorders
Trauma

98
Q

Symptoms of pulmonary embolism?

A 
Sudden onset shortness of breath
Pleuritic chest pain
Haemoptysis
Dizziness
Syncope
99
Q

Signs of pulmonary embolism?

A 
Pyrexis
Cyanosis
Tachycardia
Hypotension
Raised JVP
Pleural rub
Pleural effusion
Signs of cause e.g. DVT
100
Q

Investigations for pulmonary embolism?

A

Bloods: FBC, U&Es, LFTs, clotting factor, D-dimer
ABG
Chest x-ray
ECG
CT pulmonary angiogram (CTPA)
Ventilation-perfusion scan: for pregnancy, postpartum, renal damage

101
Q

Chest x-ray findings in pulmonary embolism?

A 
Most common: normal
Oliguria
Elevated hemidiaphragm
Wedge-shaped opacity
Horizontal linear opacities
Pleural effusion
Dilated pulmonary artery
102
Q

ECG findings in pulmonary embolism?

A

Most common: normal

Sinus tachycardia due to right heart strain

103
Q

What do you do if you suspect a pulmonary embolism?

A

Calculate a modified Wells score
> 4 -> immediate CTPA and LMWH
> 4 -> do a D-dimer -> +ve -> immediate CTPA and LMWH

104
Q

How to calculate 30 day mortality in pulmonary embolism?

A

Simplified PESI score

105
Q

Management of pulmonary embolism?

A

ABCDE assessment

Anticoagulation: either LMWH then warfarin or straight to DOAC

106
Q

Management in a very large pulmonary embolism?

A 
Oxygen if hypoxic
Morphine IV
Anti-emetic
IV access -> heparin or fondaparinux
IV fluids if hypotensive
Thrombolysis if harm-dynamically unstable
Long term anti-coagulation
107
Q

What is the prediction sore for recurrent VTE?

A

DASH score

108
Q

How to prevent pulmonary embolism and VTE happening?

A

LMWH to all immobile patients

Stop HRT and CCP pre-operatively

109
Q

What is pleural cancer called?

A

Malignant mesothelioma

110
Q

Causes of mesothelioma?

A

Asbestos exposure in 90%
Radiotherapy
Genetic predisposition

111
Q

Clinical features of mesothelioma?

A 
Chest pain
Dyspnoea
Weight loss
Finger clubbing
Recurrent pleural effusion
Signs of metastases: lymphadenopathy, hepatomegaly, bone pain/tenderness, abdomen pain/obstruction
112
Q

Investigations for mesothelioma?

A

Chest x-ray
Chest CT
Video assisted thoracoscopic surgery (VATS)
PET scan

113
Q

What does the chest x-ray look like in mesothelioma?

A

Unilateral pleural effusion
Pleural thickening
Reduced lung volumes
Parenchymal changes due to asbestos exposure: lower zone linear interstitial fibrosis, pleural calcification, pleural plaques

114
Q

What is empyema?

A

Pus in the pleural space

115
Q

Types of pleural effusion?

A

Exudate

Transudate

116
Q

What is an exudate?

A

> 30 g/l of protein

Due to increased microvascular pressure -> loss of vessel integrity (leaky vessels)

117
Q

Causes of exudative pleural effusion?

A 
Panarneumonic
Malignancy
Infection: TB, pancreatitis
Inflammation: RA, SLE
Post MI/CABG
118
Q

What is a transudate?

A

< 30 g/l of protein

Due to increased hydrostatic pressure and decreased osmotic pressure

119
Q

Causes of transudative pleural effusion?

A 
Heart failure
Liver failure
Nephrotic syndrome
Hypoalbuminaemia
Peritoneal dialysis
120
Q

How to distinguish an exudate from a transudate?

A

Protein levels

Light’s criteria

121
Q

Symptoms of pleural effusion?

A

Dyspnoea
Pleuritic pain
Cough

122
Q

Signs of pleural effusion?

A 
Tachpnoea
Reduced expansion on affected side
Tracheal deviated away from effusion
Dull percussion over effusion
Absent breath sounds over effusion
Reduced vocal resonance over effusion
123
Q

Investigations for pleural effusion?

A 
Chest x-ray
USS
CT
Pleural aspiration: biochemistry, bacteriology, cytology
Medical thoracoscopy vs VATS
124
Q

Management of a pleural effusion?

A

Drainage via thoracentesis

Pleurodesis (not if the lung isn’t fully inflated)

125
Q

What is a pneumothorax?

A

Air in the pleural space

126
Q

Types of pneumothorax?

A

Closed
Open
Tension

127
Q

What is a closed pneumothorax?

A

No communication between the airway and pleural space (seals off as the lung deflates)

128
Q

What is an open pneumothorax?

A

Air can pass freely between the airway and pleural space

129
Q

What is a tension pneumothorax?

A

Communication between the airway and the pleural space acts as a one way valve.
Air enters the pleural space on inspiration -> accumulates -> intrapleural pressure rises

130
Q

What does the increased intrapleural pressure in tension pneumothorax cause?

A

Mediastinal displacement to opposite side
Compression of the normal lung
Impairment of the systemic venous return -> cardiovascular compromise

131
Q

Causes of pneumothorax?

A

Spontaneous

Traumatic

132
Q

Causes of spontaneous pneumothorax?

A

Primary: no evidence of lung disease
Secondary: presence of underlying lung disease e.g. COPD, TB, asthma, lung abscess

133
Q

Risk factors for spontaneous pneumothorax?

A

Smoking
Tall stature
Presence of apical sub pleural blebs

134
Q

Causes of traumatic pneumothorax?

A

Post thoracic surgery
Biopsy
Chest wall injury

135
Q

Symptoms of pneumothorax?

A

Sudden onset dyspnoea

Sudden onset unilateral pleuritic chest pain

136
Q

Signs of a small pneumothorax?

A

Examination may be normal

137
Q

Signs of a larger pneumothorax?

A

Decreased/absent breath sounds
Hyper-resonant percussion
Reduced chest expansion on affected side
Resonant percussion

138
Q

Symptoms and signs of tension pneumothorax?

A 
Rapidly progressive dyspnoea
Respiratory distress
Distended neck veins
Tachycardia
Hypotension
Cyanosis
Trachial deviation away from affected side
Hyper-resonant percussion
Reduced breath sounds
139
Q

Investigations for pneumothorax?

A

Chest x-ray

ABG

140
Q

Do you need investigations to diagnose tension pneumothorax?

A

No, it is a clinical diagnosis at examination

141
Q

Management of a spontaneous pneumothorax?

A

May resolve spontaneously
Aspirate air
Chest x-ray to confirm resolution
Chest drain

142
Q

Management of a tension pneumothorax?

A

Medical emergency
Insert large-bore needle with syringe into 2nd intercostal space in midclavicular line -> converts to an open pneumothorax
Insert chest drain

143
Q

What is interstitial lung disease?

A

Diseases where there is inflammation and/or fibrosis primarily to the lung interstitium

144
Q

Types of ILD?

A

Known cause/association
Unknown cause
Miscellaneous cause and rare

145
Q

Known causes/associations of ILD?

A

Inhaled dusts/antigens/fibres: coal worker’s pneumoconiosis, asbestosis, silicosis, hypersensitivity pneumonitis

Iatrogenic: drugs (amiodarone, methotrexate, leflunamide, biologics, nitrofurantoin, sulphasalazine, bleomycin), radiation

Connective tissue disease: rheumatoid, systemic sclerosis

Smoking related: respiratory bronchiolitis ILD, desquamative interstitial pneumonia, langerhans cell histiocytosis

146
Q

Unknown causes of ILD?

A

Sarcoidosis
Idiopathic pulmonary fibrosis (IPF)
Idiopathic non-specific interstitial pneumonia (NSIP)
Crytogenic organising pneumonia (COP)
Idiopathic acute interstitial pneumonia (AIP)

147
Q

Miscellaneous and rare causes of ILD?

A 
Eosinophilic pneumonia
Lymphangioleiomyamotosis
Alveolar proteinosis
Lipid pneumonia
Lymphoytic interstitial pneumonia
148
Q

Signs of ILD?

A

Finger clubbing
Lung crepitations
Lack of wheeze
Signs of connective tissue disorders

149
Q

Investigations for ILD?

A

Chest x-ray

150
Q

Who gets idiopathic pulmonary fibrosis?

A

Older
Men
Smokers

151
Q

Symptoms of idiopathic pulmonary fibrosis?

A

Dyspnoea

Cough- usually dry

152
Q

What symptoms don’t present in idiopathic pulmonary fibrosis?

A 
Orthopnoea
PND
Haemoptysis
Wheeze
Chest pain
153
Q

Signs of idiopathic pulmonary fibrosis?

A

Bibasal fine mid and late inspiratory crackles

Finger clubbing

154
Q

Investigations for idiopathic pulmonary fibrosis?

A 
Spirometry- restrictive
Lung function- reduced volume
Chest x-rau
High resolution CR
Surgical lung biopsy
155
Q

Restrictive spirometry?

A

FEV1 < 80%
FVC < 80%
FEV1/FVC > 70%

156
Q

How to monitor disease progression in idiopathic pulmonary fibrosis?

A

Change in FVC

> 10% decline over 6-12 months = poorer prognosis

157
Q

Non-pharmacological management of idiopathic pulmonary fibrosis?

A

Smoking cessation
Treat acid reflux symptoms
Ambulatory and domiciliary oxygen if hypoxic
Pulmonary rehabilitation
Lung transplantation (if young without co-morbidities)
Early palliative care engagement

158
Q

Drugs to manage idiopathic pulmonary fibrosis?

A

Pirfenidone

Nintedanib

159
Q

Do drugs for idiopathic pulmonary fibrosis cure it?

A

No, they just slow the disease progression

160
Q

Side effects of drugs for idiopathic pulmonary fibrosis?

A 
Rash
Photosensitivity
Nausea
Dyspepsia
Weight loss
Diarrhoea
161
Q

What is sarcoidosis?

A

Systemic disease of unknown aetiology characterised by presence of non-caveating granulomas

162
Q

Symptoms of sarcoidosis?

A 
Rash
Iritis (eyes)
Arthralgia
Facial nerve palsy
Cirrhosis
Fatigue
Hypercalcaemia symptoms
Enlarge lymph nodes
Night sweats
Cough- usually dry
Dyspnoea
163
Q

Signs of sarcoidosis?

A

Chest examination is often normal
Evidence of systemic disease
Crackles rarely

164
Q

Do you stage sarcoidosis?

A

Only for the pulmonary disease?

165
Q

Sarcoidosis staging?

A

Stage 1: bilateral hilar lymphadenopathy with normal lung parenchyma
Stage 2: bilateral hilar lymphadenopathy with lung infiltrates
Stage 3: lung infiltrates without hilar node enlargement on chest x-ray
Stage 4: pulmonary fibrosis

166
Q

Investigations for sarcoidosis?

A 
Chest x-ray: for staging
Pulmonary function tests
Bloods: calcium, SACE (may be raised)
Skin test: tuberculin skin test often negative
Biopsy: for diagnosis
167
Q

Aim of sarcoidosis management?

A

Reduce symptoms and prevent permanent organ damage

168
Q

Does stage 1 sarcoidosis need treatment?

A

Hardly ever

169
Q

When do you treat stage 2 and 3 sarcoidosis?

A

Evidence of active progressive lung disease or chest symptoms

170
Q

Drugs used to manage sarcoidosis?

A

Corticosteroids: 5 phase therapy plan over 18-24 months

171
Q

Causes of hypersensitivity pneumonitis?

A

Birds
Mould
Allergens

172
Q

How to diagnose hypersensitivity pneumonitis?

A

Restrictive lung function tests

173
Q

Investigations for hypersensitivity pneumonitis?

A

Chest x-ray

High resolution CT

174
Q

What does a hypersensitivity pneumonitis HRCT show?

A

Ground glass sign

175
Q

Management of hypersensitivity pneumonitis

A

Remove the allergen
Steroids
Lung biopsy if suspicious of another cause

176
Q

What is the inheritance pattern for cystic fibrosis?

A

Autosomal recessive
1/25 are carriers
1/2,500 live births

177
Q

What does the cystic fibrosis mutation cause?

A

Thick, sticky secretions
Pancreas: blocked exocrine ducts, auto-destruction of exocrine pancreas
Intestine: bulky stools caused obstruction
Respiratory system: mucus retention, chronic infection and inflammation, destruction of lung tissue

178
Q

Clinical features of cystic fibrosis in neonates?

A

Failure to thrive
Meconium ileus
Rectal prolapse

179
Q

Clinical features of cystic fibrosis in children and young adults?

A

Respiratory: cough, wheeze, recurrent infection, bronchiectasis, pneumothorax, haemoptysis, respiratory failure, co pulmonale

GI: pancreatic insufficiency, distal intestinal obstruction syndrome, gallstones, cirrhosis

Other: male infertility, osteoporosis, arthritis, vasculitis, nasal polyps, sinusitis, hypertrophic pulmonary osteoarthropathy

180
Q

Signs of cystic fibrosis?

A

Cyanosis
Finger clubbing
Bilateral course crackles

181
Q

Investigations for cystic fibrosis?

A 
Bloods: FBC, U&amp;Es, clotting, vitamin A, D, E, annual GTT
Bacteriology: cough swab, sputum culture
Chest x-ray
Abdominal ultrasound
Spirometry
Biochemistry: faecal fat analysis
182
Q

Is cystic fibrosis obstructive or restrictive?

A

Obstructive

183
Q

Cystic fibrosis chest x-ray appearance?

A

Hyper-inflation

Bronchiectasis

184
Q

Diagnosis of cystic fibrosis?

A

Newborn screening (immunoreactive trypsinogen test)
Sweat test
Genetic testing

185
Q

Management of cystic fibrosis?

A 
Chest physiotherapy
Antibiotics for infective exacerbations and prophylaxis
Mucolytics
Bronchodilators
Annual chest x-ray
Advanced lung disease: oxygen, diuretics, non-invasive ventilation, lung or heart/lung transplant
Good nutrition
Oral pancreatic enzyme replacement
Insulin for diabetes
Fat soluble vitamin supplements
Ursodeoxycholic acid for impaired liver function
Liver transplant
Screening and treatment for osteoporosis
Fertility and genetic counselling
186
Q

Cystic fibrosis prognosis?

A

About 41 years in the UK

187
Q

What does alpha-1 antitypsin deficiency cause?

A

Pulmonary: emphysema
Hepatic: cirrhosis, hepatocellular carcinoma

188
Q

Management of alpha-1 antitrypsin deficiency?

A

Smoking cessation
Prompt treatment for lung infections
Vaccinations: flu, pneumococcal
Transplantation: liver, lung

189
Q

What is obstructive sleep apnoea hypopnea syndrome?

A

Episodes of complete/partial airway obstruction during sleep

190
Q

Risk factors for obstructive sleep apnoea?

A 
Obesity
Male
Wide neck circumference
Anatomical abnormalities e.g. receding lower jaw
Post-menopausal
PCOS
191
Q

Clinical features of obstructive sleep apnoea?

A 
Chronic snoring
Insomnia
Gasping
Breath holding
Unrefreshing sleep
Daytime sleepiness
192
Q

How to score sleep quality?

A

Epworth sleepiness score

193
Q

Investigations for obstructive sleep apnoea?

A

Epworth sleepiness score

Polysomnography sleep tests

194
Q

Management of obstructive sleep apnoea?

A 
Continuous positive airway pressure (CPAP)
Weight loss
Reduce/stop evening alcohol
Relieve nasal congestion
Advise on sleep hygiene

Year 4 Semester 2 (3 decks)

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