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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
What is chronic bronchitis?
Hyperplasia of goblet cells -> hypersecretion of mucus | Cough productive of sputum on most days for 3 months over 2 consecutive years
26
What is emphysema?
Abnormal, permanent enlargement of airspaces distal to the terminal bronchioles and destruction of their walls without obvious fibrosis
27
Types of emphysema?
Centrilobular emphysema: common in smokers | Pan-lobular emphysema: common in alpha-1 antitrypsin deficiency
28
COPD symptoms?
Dyspnoea Chronic cough Chronic sputum production
29
Physical examination of COPD?
``` 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 ```
30
Common triggers of COPD exacerbations?
Bacteria Virus Pollutants
31
Investigations for COPD?
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
32
What is the reversibility testing result in COPD?
> 200 ml and 12% of pre-drug value | If > 400 ml -> think asthma
33
How to assess severity in COPD?
Post-bronchodilator FEV1 | GOLD ABCD assessment
34
Post-bronchodilator FEV1 severity in COPD?
``` 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 ```
35
GOLD ABCD severity assessment for COPD?
A: low risk, less symptoms B: low risk, more symptoms C: high risk, less symptoms D: high risk, more symptoms
36
COPD management?
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
37
COPD drug management based on GOLD severity?
``` 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) ```
38
COPD exacerbation management?
``` Optimise bronchodilators Use a nebuliser Antibiotics Short course of oral corticosteroids Treat respiratory failure if present Oxygen Ventilation if needed ```
39
How to treat Type 1 respiratory failure?
Controlled oxygen
40
How to treat Type 2 respiratory failure?
``` Controlled oxygen Nebulisers Antibiotics Oral corticosteroids Monitor ```
41
What is bronchiectasis?
Chronic inflammation of the bronchi and bronchioles -> permanent dilation and thinning of the airways
42
Causes of bronchiectasis?
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
43
Common presentation of bronchiectasis?
Recurrent pulmonary infections
44
Bronchiectasis symptoms?
Persistent cough Copious purulent sputum Intermittent haemoptysis
45
Bronchiectasis signs?
Finger clubbing Course inspiratory crackles Crackles often clear after coughing Wheeze
46
Complications of bronchiectasis?
``` Pneumonia Pleural effusions Pneumothorax Haemoptysis Cerebral abscess Amyloidosis ```
47
Investigations for bronchiectasis?
``` 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 ```
48
Bronchiectasis signs on chest x-ray?
Tramline and ring shadows Thickened bronchial walls Cystic shadows
49
Bronchiectasis signs on CT?
Signet ring sign
50
Types of pulmonary TB?
Active infection | Latent infection
51
When is TB transmissible?
From a person with an active infection
52
Clinical features of TB?
``` Low-grade fever Anorexia Weight loss Malaise Night sweats Pleuritic pain Clubbing (due to bronchiectasis) Erythma nodosum ```
53
Clinical features of pulmonary TB?
``` Cough: dry then productive Pleurisy Haemoptysis Pleural effusion Aspergilloma/mycetoma may form in cavities Asymptomatic or atypical presentation ```
54
Investigations for active TB?
``` Chest x-ray Sputum acid-fast bacilli (AFB) smear Sputum culture FBC Nucleic acid amplification test (NAAT) ```
55
Investigations for latent TB?
Tuberculin skin test (TST) | Interferon-gamma release test (IGRAS)
56
Treatment of active TB?
Notify local public health protection NAAT for drug resistance Antibiotics
57
What are the antibiotics used in TB?
Rifampicin Isoniazid Pyrazinamide Ethambutol
58
What lung diseases can Aspergillus cause?
Asthma Allergic bronchopulmonary aspergillosis (ABPA) Aspergilloma (mycetoma) Extrinsic allergic alveolitis
59
What does ABPA stand for?
Allergic bronchopulmonary aspergillosis
60
What is the pathology of ABPA?
Type I and III hypersensitivity reactions to Aspergillus -> bronchoconstriction then permanent damage (bronchiectasis)
61
Clinical features of ABPA?
``` Wheeze Cough Sputum Mucus plugs containing fungal hyphae Dyspnoea Recurrent pneumonia ```
62
Investigations for ABPA?
``` Chest x-ray Sputum contains Aspergillus Positive skin test Aspergillus specific IgE RAST Positive serum precipitants Eosinophilia Raised serum IgE ```
63
Management of ABPA?
Prednisolone Antifungal Bronchodilators Bronchoscopic aspire for mucus plugs
64
What is aspergilloma?
A fungus ball in a pre-existing cavity e.g. from TB or sarcoidosis
65
Clinical features of aspergilloma?
``` Usually asymptomatic Cough Haemoptysis Lethargy Weight loss ```
66
Investigations for aspergilloma?
Chest x-ray Sputum culture Aspergillus skin test
67
Management for aspergilloma?
Only if symptomatic | Surgical excision for solitary symptomatic lesions or severe haemoptysis
68
Investigations for invasive aspergillosis?
``` Sputum culture BAL Biopsy -> diagnostic Serum precipitants Chest x-ray Early chest CT Serial measurements of galactomannan ```
69
Treatment of invasive aspergillosis?
Antifungals e.g. voriconazole
70
What is extrinsic allergic alveolitis?
Hypersensitivity reaction to inhaled fungal spores in sensitised individuals
71
Acute clinical features of extrinsic allergic alveolitis?
``` Fever Rigors Myalgia Dry cough Dyspnoea Fine bibasal crackles ```
72
Chronic clinical features of extrinsic allergic alveolitis?
``` Finger clubbing Increasing and exertion dyspnoea Weight loss Type 1 respiratory failure Cor pulmonale ```
73
Investigations for extrinsic allergic alveolitis?
``` 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) ```
74
Management of extrinsic allergic alveolitis?
Acute: remove allergen, oxygen, prednisolone Chronic: allergen avoidance, long-term steroids Can get compensation for some causes
75
Risk factors for bronchial carcinoma?
``` Cigarette smoking Passive smoking Asbestos Chromium Arsenic Iron oxides Radiation ```
76
Types of bronchial carcinoma?
Small cell: 15-20% | Non-small cell: > 80%
77
Types of non-small cell lung cancer?
Adenocarcinoma Squamous cell carcinoma Large cell carcinoma
78
Pathology of small cell lung cancer?
Aggressive | Neuroendocrine
79
Clinical features of lung cancer?
``` 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
Investigations for lung cancer?
Chest x-ray CT chest and abdo CT PET scan Biopsy: CT guided, bronchial, liver, VATS/thorascoscopy, mediastinoscopy, EUS, resection
81
How is lung cancer staged?
TNM staging | Tissue diagnosis: biopsy, cytology (sputum, pleural fluid)
82
Common sites of lung metastases?
``` Mediastinal/hilar lymph nodes Peripheral lymph nodes Pleura Bone Liver Skin Brain Adrenal glands ```
83
What do you need to know about a patient before making a management plan for lung cancer?
``` ECOG performance status Exercise tolerance Activities of daily living Cardiac staus Renal or hepatic dysfunction Co-morbidities Other lung disease Cognitive impairment Fraility ```
84
When is lung cancer potentially curable?
Non-small cell N staging < N3 If the patient is otherwise well and healthy
85
Management options for lung cancer?
``` Surgery Radiotherapy Chemotherapy Biologics Palliation ```
86
Types of surgery for lung cancer?
Lobectomy Pneumonectomy Wedge resection or segmentectomy
87
When do you use surgery for lung cancer?
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
What is radiotherapy for in lung cancer?
Does have a curable intent
89
Types of radiotherapy for lung cancer
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
What does chemotherapy do in lung cancer?
Extension of life | Improvement of quality of life
91
Palliation in lung cancer?
Radiotherapy for distressing complications e.g. SVCO, recurrent haemoptysis, pain (chest wall invasion, skeletal metastases)
92
Management for SVCO in lung cancer?
Dexamethasome -> reduces oedema Anticoagulation SVC stenting
93
Which cancers commonly cause secondary lung cancer?
``` Breast Kidney Uterus Ovary Testes Thyroid ```
94
What does PE stand for?
Pulmonary embolism
95
What is pulmonary embolism?
A venous thromboembolic event
96
Causes of pulmonary embolism?
Due to lower limb DVT: 80% Right sided endocarditis Tumours Fat/ai/amniotic fluid emboli
97
Risk factors for pulmonary embolism
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
Symptoms of pulmonary embolism?
``` Sudden onset shortness of breath Pleuritic chest pain Haemoptysis Dizziness Syncope ```
99
Signs of pulmonary embolism?
``` Pyrexis Cyanosis Tachycardia Hypotension Raised JVP Pleural rub Pleural effusion Signs of cause e.g. DVT ```
100
Investigations for pulmonary embolism?
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
Chest x-ray findings in pulmonary embolism?
``` Most common: normal Oliguria Elevated hemidiaphragm Wedge-shaped opacity Horizontal linear opacities Pleural effusion Dilated pulmonary artery ```
102
ECG findings in pulmonary embolism?
Most common: normal | Sinus tachycardia due to right heart strain
103
What do you do if you suspect a pulmonary embolism?
Calculate a modified Wells score > 4 -> immediate CTPA and LMWH > 4 -> do a D-dimer -> +ve -> immediate CTPA and LMWH
104
How to calculate 30 day mortality in pulmonary embolism?
Simplified PESI score
105
Management of pulmonary embolism?
ABCDE assessment | Anticoagulation: either LMWH then warfarin or straight to DOAC
106
Management in a very large pulmonary embolism?
``` 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
What is the prediction sore for recurrent VTE?
DASH score
108
How to prevent pulmonary embolism and VTE happening?
LMWH to all immobile patients | Stop HRT and CCP pre-operatively
109
What is pleural cancer called?
Malignant mesothelioma
110
Causes of mesothelioma?
Asbestos exposure in 90% Radiotherapy Genetic predisposition
111
Clinical features of mesothelioma?
``` Chest pain Dyspnoea Weight loss Finger clubbing Recurrent pleural effusion Signs of metastases: lymphadenopathy, hepatomegaly, bone pain/tenderness, abdomen pain/obstruction ```
112
Investigations for mesothelioma?
Chest x-ray Chest CT Video assisted thoracoscopic surgery (VATS) PET scan
113
What does the chest x-ray look like in mesothelioma?
Unilateral pleural effusion Pleural thickening Reduced lung volumes Parenchymal changes due to asbestos exposure: lower zone linear interstitial fibrosis, pleural calcification, pleural plaques
114
What is empyema?
Pus in the pleural space
115
Types of pleural effusion?
Exudate | Transudate
116
What is an exudate?
> 30 g/l of protein | Due to increased microvascular pressure -> loss of vessel integrity (leaky vessels)
117
Causes of exudative pleural effusion?
``` Panarneumonic Malignancy Infection: TB, pancreatitis Inflammation: RA, SLE Post MI/CABG ```
118
What is a transudate?
< 30 g/l of protein | Due to increased hydrostatic pressure and decreased osmotic pressure
119
Causes of transudative pleural effusion?
``` Heart failure Liver failure Nephrotic syndrome Hypoalbuminaemia Peritoneal dialysis ```
120
How to distinguish an exudate from a transudate?
Protein levels | Light's criteria
121
Symptoms of pleural effusion?
Dyspnoea Pleuritic pain Cough
122
Signs of pleural effusion?
``` 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
Investigations for pleural effusion?
``` Chest x-ray USS CT Pleural aspiration: biochemistry, bacteriology, cytology Medical thoracoscopy vs VATS ```
124
Management of a pleural effusion?
Drainage via thoracentesis | Pleurodesis (not if the lung isn't fully inflated)
125
What is a pneumothorax?
Air in the pleural space
126
Types of pneumothorax?
Closed Open Tension
127
What is a closed pneumothorax?
No communication between the airway and pleural space (seals off as the lung deflates)
128
What is an open pneumothorax?
Air can pass freely between the airway and pleural space
129
What is a tension pneumothorax?
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
What does the increased intrapleural pressure in tension pneumothorax cause?
Mediastinal displacement to opposite side Compression of the normal lung Impairment of the systemic venous return -> cardiovascular compromise
131
Causes of pneumothorax?
Spontaneous | Traumatic
132
Causes of spontaneous pneumothorax?
Primary: no evidence of lung disease Secondary: presence of underlying lung disease e.g. COPD, TB, asthma, lung abscess
133
Risk factors for spontaneous pneumothorax?
Smoking Tall stature Presence of apical sub pleural blebs
134
Causes of traumatic pneumothorax?
Post thoracic surgery Biopsy Chest wall injury
135
Symptoms of pneumothorax?
Sudden onset dyspnoea | Sudden onset unilateral pleuritic chest pain
136
Signs of a small pneumothorax?
Examination may be normal
137
Signs of a larger pneumothorax?
Decreased/absent breath sounds Hyper-resonant percussion Reduced chest expansion on affected side Resonant percussion
138
Symptoms and signs of tension pneumothorax?
``` Rapidly progressive dyspnoea Respiratory distress Distended neck veins Tachycardia Hypotension Cyanosis Trachial deviation away from affected side Hyper-resonant percussion Reduced breath sounds ```
139
Investigations for pneumothorax?
Chest x-ray | ABG
140
Do you need investigations to diagnose tension pneumothorax?
No, it is a clinical diagnosis at examination
141
Management of a spontaneous pneumothorax?
May resolve spontaneously Aspirate air Chest x-ray to confirm resolution Chest drain
142
Management of a tension pneumothorax?
Medical emergency Insert large-bore needle with syringe into 2nd intercostal space in midclavicular line -> converts to an open pneumothorax Insert chest drain
143
What is interstitial lung disease?
Diseases where there is inflammation and/or fibrosis primarily to the lung interstitium
144
Types of ILD?
Known cause/association Unknown cause Miscellaneous cause and rare
145
Known causes/associations of ILD?
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
Unknown causes of ILD?
Sarcoidosis Idiopathic pulmonary fibrosis (IPF) Idiopathic non-specific interstitial pneumonia (NSIP) Crytogenic organising pneumonia (COP) Idiopathic acute interstitial pneumonia (AIP)
147
Miscellaneous and rare causes of ILD?
``` Eosinophilic pneumonia Lymphangioleiomyamotosis Alveolar proteinosis Lipid pneumonia Lymphoytic interstitial pneumonia ```
148
Signs of ILD?
Finger clubbing Lung crepitations Lack of wheeze Signs of connective tissue disorders
149
Investigations for ILD?
Chest x-ray
150
Who gets idiopathic pulmonary fibrosis?
Older Men Smokers
151
Symptoms of idiopathic pulmonary fibrosis?
Dyspnoea | Cough- usually dry
152
What symptoms don't present in idiopathic pulmonary fibrosis?
``` Orthopnoea PND Haemoptysis Wheeze Chest pain ```
153
Signs of idiopathic pulmonary fibrosis?
Bibasal fine mid and late inspiratory crackles | Finger clubbing
154
Investigations for idiopathic pulmonary fibrosis?
``` Spirometry- restrictive Lung function- reduced volume Chest x-rau High resolution CR Surgical lung biopsy ```
155
Restrictive spirometry?
FEV1 < 80% FVC < 80% FEV1/FVC > 70%
156
How to monitor disease progression in idiopathic pulmonary fibrosis?
Change in FVC | > 10% decline over 6-12 months = poorer prognosis
157
Non-pharmacological management of idiopathic pulmonary fibrosis?
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
Drugs to manage idiopathic pulmonary fibrosis?
Pirfenidone | Nintedanib
159
Do drugs for idiopathic pulmonary fibrosis cure it?
No, they just slow the disease progression
160
Side effects of drugs for idiopathic pulmonary fibrosis?
``` Rash Photosensitivity Nausea Dyspepsia Weight loss Diarrhoea ```
161
What is sarcoidosis?
Systemic disease of unknown aetiology characterised by presence of non-caveating granulomas
162
Symptoms of sarcoidosis?
``` Rash Iritis (eyes) Arthralgia Facial nerve palsy Cirrhosis Fatigue Hypercalcaemia symptoms Enlarge lymph nodes Night sweats Cough- usually dry Dyspnoea ```
163
Signs of sarcoidosis?
Chest examination is often normal Evidence of systemic disease Crackles rarely
164
Do you stage sarcoidosis?
Only for the pulmonary disease?
165
Sarcoidosis staging?
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
Investigations for sarcoidosis?
``` 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
Aim of sarcoidosis management?
Reduce symptoms and prevent permanent organ damage
168
Does stage 1 sarcoidosis need treatment?
Hardly ever
169
When do you treat stage 2 and 3 sarcoidosis?
Evidence of active progressive lung disease or chest symptoms
170
Drugs used to manage sarcoidosis?
Corticosteroids: 5 phase therapy plan over 18-24 months
171
Causes of hypersensitivity pneumonitis?
Birds Mould Allergens
172
How to diagnose hypersensitivity pneumonitis?
Restrictive lung function tests
173
Investigations for hypersensitivity pneumonitis?
Chest x-ray | High resolution CT
174
What does a hypersensitivity pneumonitis HRCT show?
Ground glass sign
175
Management of hypersensitivity pneumonitis
Remove the allergen Steroids Lung biopsy if suspicious of another cause
176
What is the inheritance pattern for cystic fibrosis?
Autosomal recessive 1/25 are carriers 1/2,500 live births
177
What does the cystic fibrosis mutation cause?
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
Clinical features of cystic fibrosis in neonates?
Failure to thrive Meconium ileus Rectal prolapse
179
Clinical features of cystic fibrosis in children and young adults?
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
Signs of cystic fibrosis?
Cyanosis Finger clubbing Bilateral course crackles
181
Investigations for cystic fibrosis?
``` Bloods: FBC, U&Es, clotting, vitamin A, D, E, annual GTT Bacteriology: cough swab, sputum culture Chest x-ray Abdominal ultrasound Spirometry Biochemistry: faecal fat analysis ```
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Is cystic fibrosis obstructive or restrictive?
Obstructive
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Cystic fibrosis chest x-ray appearance?
Hyper-inflation | Bronchiectasis
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Diagnosis of cystic fibrosis?
Newborn screening (immunoreactive trypsinogen test) Sweat test Genetic testing
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Management of cystic fibrosis?
``` 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 ```
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Cystic fibrosis prognosis?
About 41 years in the UK
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What does alpha-1 antitypsin deficiency cause?
Pulmonary: emphysema Hepatic: cirrhosis, hepatocellular carcinoma
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Management of alpha-1 antitrypsin deficiency?
Smoking cessation Prompt treatment for lung infections Vaccinations: flu, pneumococcal Transplantation: liver, lung
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What is obstructive sleep apnoea hypopnea syndrome?
Episodes of complete/partial airway obstruction during sleep
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Risk factors for obstructive sleep apnoea?
``` Obesity Male Wide neck circumference Anatomical abnormalities e.g. receding lower jaw Post-menopausal PCOS ```
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Clinical features of obstructive sleep apnoea?
``` Chronic snoring Insomnia Gasping Breath holding Unrefreshing sleep Daytime sleepiness ```
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How to score sleep quality?
Epworth sleepiness score
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Investigations for obstructive sleep apnoea?
Epworth sleepiness score | Polysomnography sleep tests
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Management of obstructive sleep apnoea?
``` 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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