Respiratory Flashcards
Types of respiratory disease and examples
Obstructive e.g. COPD, asthma, bronchiectasis
Restrictive e.g. sarcoidosis, pulmonary fibrosis
Malignant e.g. small and non small cell carcinomas
Infective e.g. pneumonias, tuberculosis
Difference between obstructive and restrictive lung pathologies
- Obstructive = FEV1 <80% of the predicted value,
FVC reduced but to a lesser extent than FEV1 and
FEV1/FVC ratio < 0.7, mainly disease of breathing tubes. - Restrictive = FEV1 <80% of the predicted value and FVC proprtioanlly reduced too, FEV1/FVC ratio normal (>0.7), mainly disease of lung paranchyma.
Differentials for chest pain
Resp = Costochondritis Tietze syndrome PE Pneumonia Pneumothorax Pleural effusion Non resp = MI, angina, GORD, musculoskeletal, pericarditis.
Differentials for shortness of breathe
Resp = COPD Asthma PE Pneumothorax Pneumonia Interstitial lung disease e.g pulmonary fibrosis Bronchiectasis Non resp = severe anaemia, CHF, ACS, shock
Differentials for cough
Resp = TB Pneumonia Cystic fibrosis Pulmonary fibrosis Asthma COPD Malignancy URTI Non resp = CHF, GORD, ACE inhibitors
Haemoptysis differentials
Lung cancer Tuberculosis PE Bronchiectasis Mitral stenosis Aspergilloma Granulomatosis with polyangiitis Goodpasture's sydrome
Differentials for wheeze
Asthma Inhalation of foreign body COPD Anaphylaxis Bronchiolitis (paeds)
Differentials for stridor
Croup
Epiglottitis
Inhalation of foreign body
Carcinoma of the larynx
Common causes of CAP
Streptococcus pneumoniae
Mycoplasma pneumoniae
Haemophilus influenza
Common causes of HAP
Develops 48 hours or more after hospital admission and that was not incubating at hospital admission.
Pseudomona aeruginosa,
E.coli (gram -ve),
Kledsiella pneumoniae
Risk factor for HAP
Intubation and ventilation machinery used.
Risk factors for CAP
Over 65yrs COPD Resides in care home Cigarette smoking Alcohol use Immunocompromised
Risk stratification for pneumonia
CURB 65 C - confusion U - urea >7mmol/L R - Resp rate >30/min B - SBP <90mmHg or DBP <60mmHg 65 - aged over 65yrs
Score of 0 = low risk. Outpatient care.
Score of 1 or 2 = intermediate risk. Inpatient care.
Score of 3 or 4 = high risk. HDU/ITU care.
Use of CRB65 is increasingly being used as no need to wait for laboratory tests to assess patient’s risk.
History and examination of pneumonia
Hx: Fever Productive cough SOB Malaise and fatigue Pleuritic chest pain Confusion Presence of risk factors
O/E:
High temp, tachycardiac, tachypnoea, hypotensive.
Reduced chest expansion.
Dull to percuss
Increased tactile vocal resonance.
Crackles and reduced air entry on auscultation.
Pleural friction rub
Atypical pneumonia - Mycoplasma pneumoniae and COMPLICATIONS.
Common cause in young adults.
S+S= Dry cough, haemolytic anaemia, lower grade fever, hoarse voice, headache, pharyngitis.
Complications = Steven-Johnson syndrome, Guillian-Barre syndrome, erythema multiforme.
Rx = clarithromycin or doxycycline. (no cell wall so beta-lactams e.g. penicillin are not effective)
Atypical pneumonia - Chlamydia pneumoniae
Biphasic illness.
Lower grade fever, headache, hoarse voice, pharyngitis.
Less sudden onset.
Rx = clarithromycin or doxycycline.
Atypical pneumonia - Chlamydia psitacci
Bird fanciers!
Fever, headache, dry cough, d&v.
Rx = doxycycline.
Atypical causes of pneumonia in immunocompromised
PCP = pneumocystis jirovecii (fungal) S+S = fever, dry cough, exertion dyspnoae, desaaturations on exertion, bilateral creps. Ix = fine peri-hilar infiltrations on CXR, usually spares the apicies and lower lobes, not as focal as typical pneumonia. Rx = co-trimoxazole.
Investigating a patient for pneumonia
ABG - oxygen saturation, are they in respiratory failure.
CXR - consolidation
Sputum culture - mc&s for appropriate antibiotic use.
Blood culture - sepsis screen.
FBC, CRP - WCC and CRP raised.
CXR for patients with suspected CAP who are over 60 years of age and smoke to rule out Ca.
CXR for atypical pneumonia
Diffuse reticular or reticulonodular opacities affecting interstitium.
Complications of pneumonia
Sepsis/Septic shock pleural effusion lung abscess respiratory failure pericardities Jaundice
First line treatment for CAP
Low-medium severity: Amoxicillin 500mg TDS for 5 days.
If penicillin allergic use Doxycyline 200mg on day 1 then 100mg OD for further4 days.
If high severity (based on CRB65):
Co-amoxiclav + clarithromycin or for penicillin allergic Levofloxacin.
First line treatment for HAP
- Non-severe symptoms and signs: Co-amoxiclav If penicillin allergic or high risk of resistance use Doxycycline. - Severe S+S and needing IV: Piperacillin + tazobactam. - Suspected MRSA: Vancomycin
Types of interstitial lung disease and pathophysiology.
Disease of lung interstitium -space between alveolar epithelium and capillary endothelial.
Type of RESTRICTIVE lung disease.
- Idiopathic pulmonary fibrosis.
- Pulmonary fibrosis due to lung disease.
-Pneumoconioses/occupational lung disease.
- Extrinsic allergic alveolitis.
Diseases which cause pulmonary fibrosis
- Connective tissue disease = rheumatoid arthritis, SLE, Sjogren’s syndrome, sarcoidosis.
- Occupational = asbestos, dust, coal, silica.
Irritant inhalation = birds, mould. - Radiation.
- Drugs e.g bleomycin, methotrexate.
Over-riding features of ILD
Dry cough. Digital clubbing Dyspnoea Diffuse fine inspiratory crackles. CXR shadows.
Spirometry result of ILD
FVC proportionally lower than FEV1
Ratio of FEV1/FVC is >80%
Peak incidence of idiopathic pulmonary fibrosis
45-65yrs
S+S of idiopathic pulmonary fibrosis
Weight loss Fatigue Progressive dyspnoea Dry cough Digital clubbing Diffuse fine inspiratory crackles Reduced chest expansion
Complications of idiopathic pulmonary fibrosis
Pulmonary HTN
Cor pulmonale
Cyanosis
Respiratory failure
RFx for idiopathic pulmonary fibrosis
Male Smoker Family history Chronic aspiration e.g. GORD Dust exposure ASK ABOUT OCCUPATION!
Investigations for idiopathic pulmonary fibrosis
CXR/CT-bilateral reticular nodular shaowing, honeycomb lung if severe.
Spirometry - restrictive pattern.
ABG - PaO2 low.
FBC - raised ESR.
Bronchoalveolar lavage - high neutrophils.
Lung biopsy.
Rheumatoid factor, antinuclear factor.
Management of idiopathic pulmonary fibrosis
Oxygen
Pulmonary rehabilitation
Smoking cessation and exercise support
Lung transplant
Caplan’s syndrome
Coal worker pneumoconiosis + rheumatoid arthritis.
Coal workers pneumoconiosis
S+S: Dry cough, dysnpoea, black sputum, exertional dyspnoea.
OCCUPATIOAL Hx!
Ix: restricitive pattern on spiromtry, CXR shoes large nodular fibrotic masses in UPPER lobes.
Rx: financial compensation, avoid exposure, smoking cessation.
Above is similar for Silicosis.
Types of occupational lung disease
Coal workers pneumoconiosis
Asbestosis
Silicosis/ Potter’s rot
Pleural mesothelioma
Asbestosis
5-10yrs from exposure.
S+S: dry cough, digital clubbing, dysnpoea, diffuse inspiratory crackles (velcro).
Blue asbesto fibres are the worst :(
Ix: restrictive pattern on spirometry. CXR shows ground-glass opacification, asbestos bodies (small nodular opacities), sputum microscopy shows asbestos bodies/fibres.
Mx: avoid exposure, smoking cessation, financial compensation.
RF for mesothelioma.
Extrinsic allergic alveolitis
- Hypersensitivity pneumonitis
- Type 3 hypersensitivity reaction, non IgE mediated.
- Sensitised patients inhale allergenand cause inflammation of alveoli and distal bronchioles.
-S+S: acute fever, rigors, SOB, cough, malaise. Chronic weight loss, exertional dyspnoea, type 1 resp failure.
-Ix: raised inflammatory markers, CXR/CT shows diffuse interstitial shadowing, ground-glass, BAL, spirtomtry shows restrictive pattern.
Mx: remove allergen exposure, oxygen, prednisolone, financial compensation, smoking cessation.
Allergens for EAA
Bird fanciers: bird poo Farmers: mushroom spores, mouldy hay Sugar cane fibres Cotton fibres Malt worker exposure Cheese-maker expsoure
FEV1 and FVC definition
FEV1 = the volume exhaled in the first second after deep inspiration and forced expiration. FVC = the total volume of air that the patient can forcibly exhale in one breath after maximum inhalation
Origin of thrombi in PE
Deep veins of calf or pelvis. Dislodge and travel to to pulmonary arterial tree where they come lodged in narrowing vessels.
Risk factors for PE
Immobilisation (long flight, bed rest, post-op)
COCP
Malignancy
Pregnancy and other Hypercoagulable states.
Genetic factors = factor V Leiden, antiphospholipid syndrome, protein C or S deficiency.
Clot formation triad
Virchow’s triad:
Blood stasis
Endothelial damage
Hypercoagulablity / Clotting system activation
Types of embolus
Thrombus Amniotic fluid Fat Air Tumour
Presentation of PE
Sudden onset chest pain Dyspnoea Tachycardia Tachypnoea Cough Syncope Hypotension Fever Increased JVP Signs of shock Unilateral calf swelling Haemoptysis
Investigations in suspected PE
- ECG - S1Q3T3, sinus tachycardia, RBBB.
- ABG - low PaO2 and PaCO2.
- D-Dimer - elevated but not SPECIFIC.
- CT pulmonary angiogram - assess clot size, location, number.
- CXR - exclude other causes, oligaemia of effected area.
FBC, U&E, Clotting screen
Scoring for DVT and PE
Well’s Score
Cause of high d-dimer
PE, sepsis, malignancy, pregnancy, post-operative, DIC, VTE.
Management of suspected PE
- A-E assessment and intervene when needed e.g. IV access, oxygen support.
- Oxygen and analgesia (morphine).
- Anticoagulate - LMWH e.g dalteparin subcut. Commence oral anticoagulant e.g warfarin.
- Thrombolysis if haemodynamically unstable e.g. hypotension. IV streptokinase or alteplase.
Anticoagulation post PE
3 months of warfarin aiming for INR 2.5-3.
Types of pneumothorax
Primary pneumothorax = spontaneous.
Secondary pneumothorax = as a complication of an underlying pulmonary disease.
Traumatic pneumothorax = penetrating or blunt injury to chest e.g. rib fracture, stabbing, poor central venous catheter placement.
Tension pneumothorax = intrapleural pressure > atmospheric pressure. Can occur after any of the above pneumothoraces and is an emergency!
Those at risk of spontaneous pneumothorax
Young, slim tall males with +ve family history.
Those at risk of secondary pneumothorax
COPD Sever asthma Recent invasive medical procedure TB HIV related pneumocystis jirovecii. Marfan's syndrome
S+S of pneumothorax
Sudden onset unilateral pleuritic chest pain.
Extreme and worsening dyspnoea.
Hyper-resonant area on percussion.
Reduced chest expansion.
Absent/diminished breath sounds.
In tension pneumothorax will have trachea deviation and mediastinum shift AWAY from affected side. Hemidiaphragm depression.
Investigations for pneumothorax
ABG
CXR - area of increased opacity, mediastinal shift in tension,
ECG
Management of pneumothorax (NOT TENSION)
If v small and not symptomatic can leave.
If needs intervention: supplementary O2. try and aspirate, if unsuccessful –> percutaneous aspiration/chest drain.
Management of tension pneumothorax
DO NOT CXR - start RX!!!
Immediate needle compression with cannula.
Oxygen therapy.
Chest drain with tube thoracostomy.
Prophylaxis for recurrent pneumothorax
Pleurodesis
Pleuritic chest pain differentials
ACS Aortic dissection Pneumothorax PE Pneumonia Malignancy
Differentials for bilateral hillar lymphadenopathy on X-ray
TIME Mnemonic TB Inorganic dust e.g. silicosis Malignancy (lymphoma, carcinoma) EAA (bird fancier's lung) Sarcoidosis
Safe triangle for chest drain insertion
Anterior border of latissimus dorsi
Lateral border of pec major
Horizontal line from nipple.
Axilla apex.
Criteria for pleural effusion
Light’s criteria
If pleural fluid has a protein concentration of 25-35g/L then the sample must be analysed using Light’s Criteria
Light’s Criteria
An effusion is considered an exudate if anyone one of the following criteria are met:
- Pleural fluid protein to serum protein ratio greater than 0.5.
- Pleural fluid lactate dehydrogenase to serum LDH ratio
greater than 0.6.
- Pleural fluid level >2/3 of upper value for serum LDH.
S+S of pleural effusion
Pleuritic chest pain SOBOE Reduced chest expansion (unilateral). Stony dull percussion. Decreased breath sounds. Bronchial breathing.
Investigations for pleural effusion
- CXR - blunted costaphrenic angle, ‘white-out’, meniscus at fluid level.
- US to guide diagnostic tap.
- Pleural aspiration: cytology, protein, lactate dehydrgensase, pH, gram stain, culture and sensitive.
- Pleural biopsy.
- FBC for infection and anaemia.
- CT thorax
Management of pleural effusion
Drainage if symptomatic.
Pleurodesis for recurrent effusions.
Transudates return quickly when drained so treat cause before draining them.
Pleurodesis
Use Bleomycin, tetracyclin or talc.
Massive and small haemothorax
Massive = blood volume of >1.5L, Rx with thoracotomy. Small = blood volume <1.5L, Rx with chest drain or medical management.
Causes of transudate effusions
- Increased venous pressure: Heart failure and Renal failure = fluid overload.
- Hypoproteinaemia: Hepatic failure, malabsorption
- Hypothyroidism
- PE
- Meig’s syndrome (triad of benign ovarian tumour + ascites + pleural effusion).
Causes of exudate effusions
More leaky pleura capillaries. Malignancy, mesothelioma, lymphoma Infection/pneumonia Rheumatoid arthritis, SLE, Sarcoidosis TB Empyema
Pus in pleural space
Empyema, fluid if turbid/yellow colour.
Fat in pleural space
Chylothorax
Difference between exudate and transudate pleural effusions
Transudate = protein <25g/L, hydrostatic and oncotic forces dysfunction. Exudate = protein >35g/L, increased permeability of pleura from inflammation.
If multinucleated giant cells in fluid what are the potential causes of the pleural effusion?
Rheumatoid arthritis
If abnormal mesothelial cells in fluid what are the potential causes of the pleural effusion?
Mesothelioma
If there are lots of mesothelial cells in the fluid what are the potential causes of the pleural effusion?
Pulmonary infarction
If there are lymphocytes in the fluid what are the potential causes of the pleural effusion?
TB, Rheumatoid arthritis, SLE, Sarcoidosis, malignancy.
5 groups who are eligible for pneumococcal vaccine
Elderly >65yrs
Heart failure, liver failure, renal failure
Diabetics
Immunocompromised pts (splenectomy, AIDS, chemo)
Risk factors for COPD
Smoking Exposure to dust, chemicals, noxious gases, and particles (such as coal) Air pollution Genetics Male gender
Genetic link in COPD
alpha1-antitrypsin deficiency. Consider if S+S point to COPD and is under 40yrs.
Pathophysiology of COPD
Progressive and non-reversible airway obstruction. Air is obstructed due to: Airway disease (obstructive bronchiolitis) \+ Parenchymal damage (emphysema), resulting from an enhanced inflammatory response.
Complications of COPD
Sepsis Secondary polycythaemia (chronic hypoxia) seen as increased haematocrit on FBC. Frequent chest infections Cor pulmonale Depression/anxiety
Cor pulmonale
Right heart failure secondary to lung disease.
Mostly due to pulmonary HTN as a consequence of hypoxia.
S+S of COPD
Chronic, productive cough
Poor exercise tolerance/exertion breathlessness
Frequent chest infections
Wheeze
Dyspnoea Cyanosis Use of accessory muscles on respiration Decreased chest expansion Audible wheeze Hyperinflated chest Decreased breathe sounds
Investigating COPD (non-acute)
CXR Spirometry - FEV1/FVC ratio <0.7 FBC (polycythaemia) Sputum culture ECG to assess cardiac function
Spirometry measures for severity of obstructive respiratory disease
Stage 1 = mild — FEV1 greater or equal to 80%.
Stage 2 = moderate — FEV1 50-79% of predicted value.
Stage 3 = severe — FEV1 30-49% of predicted value.
Stage 4 = very severe — FEV1 <30% of predicted value.
What can be used to assess shortness of breath
Medical research council dyspnea scale
Non-medical parts to management of COPD
Smoking cessation advice
Pneumococcal vaccine
COPD education and information
Pulmonary rehabilitation
Medical management of COPD (Chronic)
1) SABA (salbutamol) or short-acting antimuscarinic (ipratropium bromide).
2) LABA (salmeterol) + ICS (beclometasone)
3) LABA + LAMA + ICS
Acute COPD exacerbation management
A-E assessment, IV access, Oxygen supplementation (aim for sats 88-92% to prevent hypercapnia).
1) Nebulised salbutamol + ipratropium
2) IV hydrocortisone or oral prednisolone if able to tolerate
3) Consider antibiotics if infective cause
4) IV amiophylline
5) Consider intubation and ventilation
Emphysema
Histological diagnosis.
Elastin breakdown, permanent destruction and enlargement of alveoli.
Chronic bronchitis
Clinical diagnosis.
Cough and sputum production for most days of 3 months in 2 successive years.
Differences between asthma and COPD (according to NICE)
COPD = smokers, over 35yrs, chronic productive cough, persistent and progressive breathlessness, less variation day-to-day and diurnally.
Asthma = Under 35yrs, more variability in symptoms esp at night and day-to-day, more reversibility with bronchodilators.
Type 1 resp failure
Hypoxia with normal or low PaCO2.
Ventilation / perfusion mismatch
Type 2 resp failure
Hypoxia + hypercapnia
Alveolar hypoventilation
Pink puffers
- Emphysema: pink skin, pursed lips, barrel chest, decreased breath sounds, no cough
- Tachypnoea + increased minute ventilation
- CO2 responsive -> compensatory hyperventilation -> T1RF
Blue bloaters
- Bronchitis: cyanosis, crackles + wheeze, obesity, peripheral oedema
- Purulent sputum, chronic productive cough
- CO2 retention (insensitive to hypercapnia drive)
Renal symptoms + respiratory symptoms
Goodpasture’s syndrome.
Antiglomerular basement membrane antibodies.
Acute glomerulonephritis + haemoptysis, pulmonary haemorrahge
Definition of pulmonary HTN
Mean pulmonary artery pressure >25mmHg at rest, or >30mmHg on exercise.
S+S of pulmonary HTN
Breathlessness on exertion Fatigue Chest pain Palptiations Peripheral oedema Syncope
O/E: cyanosis, clubbing, RHF signs (raised JVP), scleroderma signs
Investigating pulmonary HTN
Find cause: rheumatology screen, LFTs. ECG - right heart hypertrophy (R wave in V1-V3, S wave in V4-V6). RBBB. Spirometry Chest XR Echocardiogram BNP (high in PHTN) CTPA DIAGNOSTIC: Right heart catherisation
Some causes of pulmonary HTN
SLE and other connective tissue diseases Left heart failure (MI, HTN). COPD Pulmonary embolism Sarcoidosis.
Management of pulmonary HTN
Refer to specialist.
Non-medical = avoid pregnancy/contraception advice, annual flu vaccination, lung transplant.
Medical = 1) Phosphodiesterase-5 inhibitors
e.g. Sildenafil or tadalafil
2) Endothelin recepter antagonists e.g. bosentan
3) Prostanoids e.g. IV epoprostenol
Pathophysiology behind bronchiectasis
Dilated bronchi and thickening of their walls.
Causes of bronchiectasis
LRTI and URTI
Congenital: CF, ciliary dyskinesia (Kartagener’s syndrome)
Obstruction: endobronchial tumour, foreign body inhalation.
Infective: URTI and LRTI, TB, HIV, measles
Rheumatoid arthritis
UC
Allergic bronchopulmonary aspergillosis.
S+S of bronchiectasis
Purulent sputum production - mild = ywlloy, severe = khaki.
Chronic cough
Breathlessness
Intermittent haemoptysis
Non-pleuritic chest pain
O/E: coarse crackles whcih shift on cough, wheeze, rhonchi, finger clubbing.
Investigating bronchiectasis
Sputum culture: gram -ve = P.aeruginosa. gram +ve = S.aureas, S.pneumonia. CXR - thickened bronchial walls, cystic shadows if cysts present. High resolution CT - imaging of choice. Post-bronchodilator spirometry (obstructive pattern). Investigate cause (sweat test for CF, bronchoscopy, IgE skin prick test)
Infections which form cysts
S.aurea H.influenza S.pneumonia P.aeruginosa A.fumigatus
Management of bronchiectasis
Exercise
Airway clearance physio therapy.
Mucolytics e.g. Carbocisteine
Inhaled bronchodilators + Inhaled hypertonic saline.
Antibiotics for infective episodes (amoxicillin or ciprofloxain if severe)
Hypersensitivity reaction especially common in CF or asthma patients
allergic bronchopulmonary aspergillosis
Mould in Allergic bronchopulmonary aspergillosis
Aspergillus fumigatus
2 types of hypersensitivity reaction in Allergic bronchopulmonary aspergillosis
Type 1 = IgE mediated
Type 3 = IgG mediated
Presentation of allergic bronchopulmonary aspergillosis
Hx of asthma or CF Productive cough Mucus plugs Wheeze FEVER Pleuritic chest pain
Investigating allergic bronchopulmonary aspergillosis
Skin test for A.fumigatus sensitivity (+ve)
Serum IgE levels (high)
FBC for eosinophil count (high)
CXR (upper and middle infiltrates)
Management of allergic bronchopulmonary aspergillosis
Oral corticosteroids e.g. prednisolone.
Antifungal e.g. Itraconazole.
Optimise asthma or CF Mx.
Avoid exposure to mould.
Types of lung cancers
Non-small cell: Squamous cell carcinoma, Large-cell carcinoma, Adenocarcinoma
Small cell carcinoma
Malignant mesothelioma (pleura tumour)
Risk factors for lung tumours
Smoking
Passive smoking
Asbestos exposure
Radiation (radon)
Which lung tumour, if untreated, has the best survival time
Squamous cell carcinoma. Least like to metastasise too.
S+S of a lung tumour
Cough Haemoptysis Dysnpnoea Chest pain Weight loss
Anaemic
Clubbing
Can have normal resp examination
Palpable supraclavicular or axillary nodes.
What does a hoarse voice mean in the presence of a suspected lung tumour
Compression of the recurrent laryngeal nerve
Pancoast’s tumour
Causing Horner’s syndrome - miosis, ptosis, anhydrosis. Can be caused by any histological type of lung tumour by mostly adenocarcinomas and sqamous cell carcinomas
- Common substance secreted by squamous cell carcinomas.
- Common substance secreted by small cell tumours.
- Common substance/disorder from carcinoid tumours.
- Parathyroid hormone leading to hypercalcaemia and bone destruction.
- ACTH leading to Cushing’s
- Carcinoid syndrome from excessive serotonin.
CXR of a squamous cell carcinoma
Hilar mass
Cavitation
What disease is associated with adenocarcinomas
Pulmonary fibrosis and honeycomb lung
What cells to adenocarcinomas arise from
Golbet cells, type 2 pneymocytes and other glandular cells
Common sites for lung adenocarcinomas to metastasise to
Pancreas, GI tract and ovaries
What cells do small cell carcinomas arise from
Neuroendocrine cells, high occurence of paraneoplastic syndrome
Complications of lung tumours
Paraneoplastic syndrome
Recurrent laryngeal nerve palsy (hoarse voice)
Horner’s syndrome
SVC obstruction
Hypertrophic pulmonary osteoarthropathy - Painful arthropathy of the wrists, ankles, and knees
Investigating a lung tumour
2 week referral CXR.
CT scan for diagnosis and staging
PET-CT
Endobronchial ultrasound transbronchial needle aspiration for biopsy
Management of a lung tumour
Smoking cessation
Education, information and support (macmillan)
Non-small cell carcinomas - excision + postop chemotherapy +/- radiotherapy.
Small cell carcinomas - platinum based chemotherapy if later staged or excision if early stage.
What substance is associated with malignant mesothelioma
Asbestos
S+S of malignant mesothelioma
Dyspnoea
Chest pain
Weight loss
Clubbing
Pleural effusion
Signs of met
Ix for mesothelioma and treatment
CXR - pleural effusion, unilateral pleural thickening
Thoracoscopy biopsy to confirm.
No cure - pallative care
Signs on an CXR that it is a metastatic lesion rather than a primary tumour
No cavitation, well circumscribed.
If large = cannonball e.g. kindey, bowel, uterus, testis
If small nodules = snowstorm e.g. breast, bladder, prostate, thyroid.
Granulomatosis with polyangiitis
Wegener’s granulomatosis
Organs invovled in granulomatosis with polyangiitis and signs + symptoms
ENT, Lungs and Kidneys
Lung = rhinorrhoea, epitaxis, sinus pain, cough, haemoptysis, dyspnoea, rhonchi, saddel-shaped nose from chronic rhinorrhoea.
ENT = conjunctivits, uveitis, periorbital oedema from kidneys
Kidneys = glomerulonephritis, proteinuria, haematuria, oedema.
Ix and Mx in granulomatosis with polyangiitis
serum cANCA
Lung = CT chest
Kidney = urinalysis and microscopy
Mx = methylprednisolone + cyclophosphamide
Severe acute respiratory syndrome
SARS CoV Virus
Persistent fever, rigors, myalgia, dry cough, diarrhoea, headache.
Low WCC, abnormal CXR. Blood cultures
Supportive maangement. Contact trace. Isolate patient. Antivirals e.g. Lopinavir
Pathophysiology behind acute respiratory distress syndrome
Non-cardiogenic pulmonary oedema + diffuse lung inflammation
Risk factors for ARDS
Sepsis Gastric aspiration Pneumonia Severe trauma Blood transfusion Pancreatitis Smoke inhalation Burns
S+S for acute respiratory distress syndrome and diagnostic criteria
Fever, cough, pleuritic chest pain. Tachycardic, tachypnoeac, hypoxic, cyanotic, bilateral fine inspiratory crackles. To diagnose: - Acute onset of symptoms (<1week) - Bilateral opacitiy on CXR - PaO2/FiO2 < 300 on PEEP or CPAP - Lack of CHF as diagnosis.
Investigations for ARDS
ABG
CXR - BILATERAL INFILTRATES.
Bloods - FBC, U+E, LFT, CRP, blood cultures, amylase, clotting screen.
Management of ARDS
A-E CPAP Oxygen, mechanical ventilation. Fluids Arterial line in situ. Consider ABx for infective cause.
Which bug can cause pneumonia and haemolytic anemia, Steven-Johnson Syndrome, Guillian-Barre syndrome?
Mycoplasma pneumonia
Meaning of PE S1Q3T3 ECG
Prominent S wave in lead I
Q wave and inverted T wave in lead III
Acute asthma treatment
1) A-E resuscitation including oxygen supplementation (target sats 94-98%)
2) Beta2-agonist bronchodilator
3) IV Hydrocortisone
4) Ipratropium bromide (nebulised)
5) Consider IV magnesium sulphate
Management of chronic asthma (adults)
1) short acting beta agonist e.g salbutamol.
2) + low dose ICS e.g. beclametasone.
3) + leukotriene receptor antagonist e.g. Montelukast.
4) + long acting beta-agonist e.g. salmeterol with or without the Montelukast.
5) MART regime with specialist.
When to give a sore throat Abx
FeverPAIN:
- Fever
- Purulence (pus on tonsils)
- Attend rapidly (within 3 days after onset of symptoms)
- Severely Inflamed tonsils
- No cough or coryza (inflammation of mucus membranes in the nose)
Score of 4-5 will benefit form ABx e.g. Phenoxymethylpenicillin
A non-caseating granuloma with multinucleate giant cells. Commonly causing respiratory symptoms?
Good ∆∆ for TB?
Sarcoidosis.
5 places where sarcoidosis commonly involve and the presentations of each?
- Pulmonary = cough, shortness of breathe, wheeze, lymphadenopathy.
- Cutaneous = lupus pernio, papular plaques on nose, cheeps, lips and ears.
- Ocular = anterior uveitis, photophobia, red painful eye, blurred vision.
- Cardiac = heart block, pulmonary HTN (haemoptysis)
- Neurosarcoidosis = headache, seizures, CN palsy.
Non-specific symptoms = chronic fatigue, weight loss, low fever.
Pathognomonic of sarcoidosis
Lupus pernio
Ix and Rx for sarcoidosis
CXR = hilar lymphadenopathy and bilateral infiltrations. bronchoalveolar lavage/biopsy.
FBC = anaemia, U+E = raised urea and creatinine, LFT = raised enzymes, Metabolic profile = Raised Ca, LyFT = restrictive pattern, ECG.
Exclude TB = QUANTIferon test.
Mx = prednisolone, methotrexate, anti-TNF.
