Respiratory Flashcards
1
Q
How is asthma characterised pathologically?
A
chronic inflammatory airway condition characterised by:
- AIRWAY LIMITATION
obstruction caused by bronchospasm, oedema, mucous plugging, hypertrophy of smooth muscle - AIRWAY HYPER-RESPONSIVENESS
airways easily constrict in response to triggers - AIRWAY INFLAMMATION
Mast cells produce histamine and neutrophils drive inflammatory response so smooth muscle of bronchioles becomes hypertrophied
2
Q
What are the classical symptoms of asthma?
A
breathlessness
cough
wheeze
chest tightness
3
Q
When are symptoms of asthma made worse?
A
diurnal variation - worse at night and early morning allergens e.g. pets, fur, pollen, grass cold air after beta blockers or NSAIDs exercise
4
Q
What is asthma associated with?
A
FH or PMH of atopy (asthma, eczema, allergens, hay fever)
5
Q
Which investigations should be done if suspect asthma?
A
- SPIROMETRY
FEV1/FVC <0.7 - significant airway OBSTRUCTION
-> do other investigations +/- start Rx - PEAK EXPIRATORY FLOW RATE
diurnal variation of PEF >20% after monitoring twice daily for 2-4 weeks - BRONCHODILATOR REVERSIBILITY TESTING
>200ml vol / >12% improvement in FEV1 in response to inhaled salbutamol - FRACTIONAL EXHALED NITRIC OXIDE TESTING
confirms eosinophilic airway inflammation to support asthma diagnosis - DIRECT BRONCHIAL CHALLENGE TESTING
with histamine or metacholine
6
Q
How is asthma managed non pharmacologically?
A
smoking cessation avoid allergens , beta blockers, NSAIDs check inhaler technique annual follow up at GP annual influenza vaccinations asthma control questionaire
7
Q
How is asthma managed long term?
A
- inhaled short acting beta agonist e.g. salbutamol
- inhaled corticosteroid e.g. beclometasone, budesonide (if using SABA >3x/ week or woken up at night)
- ICS + leukotriene receptor antagonist e.g. montelukast
- ICS + long acting beta 2 agonist e.g. Salmeterol
refer to resp specialist if still uncontrolled
8
Q
how is an acute exacerbation of asthma severity assessed?
A
MODERATE SEVERITY
if PEFR 50-70%
normal speech
ACUTE SEVERE SEVERITY
if PEFR 33-50%
tachypnoea, tachycardia
inability to complete sentences, accessory muscle use
LIFE THREATENING
if PEFR <33%
altered consciousness or confusion
cyanosis, silent chest, exhaustion
9
Q
How is an acute asthma attack managed?
A
- if severe severity, admit to hospital
- oxygen therapy with face mask
- nebulised salbutamol
- prednisolone (IM Methylpred if can’t be swallowed)
- nebulised ipratropium bromide if poor response
- other options: IV theophylline, IV magnesium sulphate, IV salbutamol, intubate and ventilate if exhausted
10
Q
What is COPD?
A
chronic slowly progressive, irreversible disease of airway obstruction caused by inflammatory response to noxious substances in the lungs
11
Q
How is copd caused?
A
SMOKING ****
+ coal mining, genetic (anti 1 trypsin deficiency)
12
Q
List pathological features of COPD
A
- mucus hypersecretion
- inflammation and scarring
- loss of elasticity in alveoli
- progressive and irreversible
13
Q
What are the types of COPD?
A
- emphysema “pink buffer” : pink skin, pursed lips, old, thin, barrel chest -> T1 RF
- chronic bronchitis “blue bloater” : peripheral oedema, overnight, cyanosis, crackles, wheeze, purulent sputum -> CO2 retention
14
Q
What are the symptoms of COPD?
A
cough + sputum
SOB on exertion
wheeze
recurrent chest infections
+ fatigue, weight loss, haemoptysis
15
Q
What are the signs of COPD on examination?
A
chest hyperinflation and barrel chest pursed lip breathing use of accessory muscles in respiration cyanosis wheeze reduced chest expansion raised JVP peripheral oedema
16
Q
What are the possible complications of COPD?
A
depression reduced quality of life secondary polycythaemia cor pulmonale - due to RHF after long standing COPD pneumonia
17
Q
How is COPD investigated?
A
SPIROMETRY
FEV1: FVC <0.7% and IRREVERSIBLE with bronchodilators
FEV1 >50% = steroid unresponsive
+ Chest x-ray to exclude other pathology (flattened diaphragm, increased intercostal spaces) + FBC (anaemia or secondary polycytheamia)
18
Q
Describe what is involved in the early management of COPD /non drug therapy
A
smoking cessation (NRT, champix, buproprione)
optimal nutrition/ balanced diet, BMI 20-25
pulmonary rehabilitation
yearly vaccinations
screen for depression
physiotherapy of excess sputum
refer to OT/ social services if not coping with ADL
19
Q
How is COPD managed long term?
A
SABA (salbutamol inhaler) or SAMA- short acting muscarinic antagonist (ipratropium)
If persistent exacerbations/ breathlessness…
if FEV >50% -> LABA (Salmeterol) + LAMA (inhaled tiotropium) (Stop SAMA) + SABA
if FEV <50% (steroid responsive) -> LABA + LAMA + ICS (stop SAMA)
increase doses if persistent and oxygen therapy
20
Q
How is COPD acutely managed?
A
- assess severity
- increase SABA
- oxygen (aim for 88-92% sats)
- oral corticosteroids (prednisolone) OD for 5 days
21
Q
How is an infective exacerbation of COPD managed?
A
if +ve sputum culture / purulent sputum - most commonly H. influenza
S - steroids (prednisolone) for 5 days H - heparin O - oxygen N - nebulised bronchodilator A - antibiotics e.g. co-amoxiclav for 5 days
22
Q
How is end stage COPD managed?
A
coordinate care with district nurses, palliative care, social services, COPD nurse specialist
ensure they have advanced care plan
opioids used for breathlessness
Long Term Oxygen Therapy increases survival - only given if stop smoking
23
Q
What are the common causes of community acquired pneumonia?
A
streptococcus pneumonia **
haemophilus influenza
mycoplasma pneumonia
+ staph aureus (IVDU, elderly) , Legionella (travelled to Spain, air conditioning), klebsiella (alcoholics, diabetics)
24
Q
What factors would point you towards a cause of mycoplasma pneumonia?
A
dry cough erythema multiform (target rash) autoimmune haemolytic anaemia bilateral radiculo-nodular shadowing on x -ray
25
What are the common causes of hospital acquired pneumonia?
```
gram -ve enterobacteria - E.coli
staph aureus
pseudomonas (CF, bronchiectasis)
Klebsiella
pneumocitis jirovecci pneumonia (HIV)
```
26
Describe the symptoms of pneumonia
```
cough w/ purulent sputum
SOB
fever / riggers
malaise
weight loss
```
27
What are the signs on examination of pneumonia?
```
tachycardia, tachypnoea
cyanosis
pyrexia
confusion
signs of consolidation of auscultation - dull percussion, bronchial breathing, crackles, reduced chest expansion
```
28
What are the possible complications with pneumonia?
pleural effusion
empyema
lung abscess
sepsis
29
How is pneumonia diagnosed and investigated?
1. CHEST X - RAY *
2. SPUTUM SAMPLE for MCandS
test for type of bacteria causing
do a LEGIONELLA URINARY ANTIGEN or pneumococcal urinary antigen
3. OBS and ABG
low oxygen sats, high RR
4. septic screen
FBC, UandE, blood cultures, CRP, LFT
30
How is the severity of pneumonia assessed?
CURB65 -1 point for each
```
C - confusion (AMT <8)
(U - urea >7mmol/l)
R - Resp rate >30/min
B - blood pressure <90 systolic, <60 diastolic
65 - over age of 65 y/o
```
31
How is the CURB65 score interrupted?
0-1 points = oral abs, treat in the community depending on available social support
1-3 points = IV Abx and hospital referral
>3 points = high mortality risk, consider ITU and urgent admission
32
How is pneumonia managed in hospital?
1. antibiotics
0-1 pts = amoxicillin 500mg TDS for 5 days
1-2 pts = amoxicillin + clarithromycin (for atypical cover) for 7-10 days
if penicillin allergic = doxycycline
if severe / sepsis = co-amoxiclav
2. oxygen
ensure sats >94%
3. IV fluids
4. VTE prophylaxis
5. analgesia
6. follow up if not improving -> prescribe 2nd antibiotic and arrange x-ray
33
What is a pleural effusion?
accumulation of fluid (>10-20ml) within the pleural space (between visceral and parietal pleura)
34
how are pleural effusions classified?
LIGHTS CRITERIA
TRANSUDATE <30g/L protein (LOW)
= disruption of hydrostatic and oncotic pressure across pleural membranes
e.g. heart failure, cirrhosis, nephrotic syndrome
EXUDATE >30g/L protein (HIGH)
= increased capillary permeability of pleura due to inflammation
e.g. malignancy, pneumonia, TB, dresslers syndrome
35
What are the main causes of pleural effusion?
1. malignancy - commonest cause >60 y/o, usually caused by metastatic cancer
2. pneumonia - 60% of pts with pneumonia
3. TB - due to delayed hypersensitivity reaction to mycobacteria released into pleural space
4. Rheumatoid artrhitis
+ PE, following asbestos exposure, haemothorax
36
How does a pleural effusion present?
```
asymptomatic
progressive breathlessness
pleuritic chest pain
dry cough
chest "heaviness"
```
37
What are the signs on examination suggesting a pleural effusion?
stony dull percussion *
unilateral reduced chest expansion
quiet breath sounds
38
How is a pleural effusion investigated?
1. Chest X-ray - blunting of costophrenic angles
2. ultrasound guided pleural aspiration with 21g needle and syringe (diagnostic or therapeutic) - test pleural fluid for cytology, MCandS, protein, glucose, colour, amylase
3. contrast CT
39
What does the colour of the pleural fluid aspirated from a pleural effusion indicate?
clear -> transudate/ exudate
turbid/ yellow -> empyema
haemorrhagic -> malignancy, PE, trauma
40
how is a pleural effusion managed?
manage underlying disease
symptomatic pleural tap or chest drain or through pleural ASPIRATION
pleurodesis with bleomycin / tetracycline if recurrent
41
List the pulmonary differentials for breathlessness?
```
pneumonia
asthma / COPD exacerbation
pneumothorax
pleural effusion
pulmonary embolism
lung collapse
```
42
define pneumothorax
accumulation of air within the pleural space
43
What are the risk factors for a pneumothorax?
PRIMARY SPONTANEOUS
male, thin, young, smoking
SECONDARY SPONTANEOUS
pre existing lung disease e.g. COPD, CF, TB
TRAUMATIC
44
What are the symptoms of pneumothorax?
sudden breathlessness
pleuritic chest pain
sweating
45
What are the signs on examination of pneumothorax?
```
tachycardia
tachypnoea
reduced chest expansion
increased resonance on affected side
reduced breath sounds
```
46
What are the differentials for chest pain?
CARDIAC - acute coronary syndrome, stable angina, pericarditis, dissecting aortic aneurysm
RESP - pulmonary embolism, pneumothorax, pleural effusion,
GI- GORD
MSK - musculoskeletal chest pain
47
What are the types of pneumothorax and what is the pathophysiology of each?
OPEN- pleural cavity pressure is less than atmospheric pressure
CLOSED - pleural cavity pressure is equal to the atmospheric pressure
TENSION - when the pleural cavity pressure is greater than atmospheric pressure -> air being let in and not out -> mediastinum shifts and lung deflates -> compresses great veins -> decreased venous return to the heart
48
Which type of pneumothorax is a medical emergency?
TENSION PNEUMOTHORAX
rapid development of severe symptoms -> tracheal deviation, tachycardia, hypotension
49
How is a primary pneumothorax managed?
if <2cm and asymptomatic then will resolve spontaneously
if <2cm and symptomatic, aspiration
if >2cm, chest drain
50
Where is a chest drain inserted?
mid axillary intercostal space 4-6 with pain relief
water seal rises in inspiration, falls in expiration
51
How is a secondary pneumothorax managed?
if >50 y/o and >2cm -> chest drain inserted and admitted for 24 hours
52
How is a tension pneumothorax managed?
aspiration - immediate needle thoracotomy into 2nd intercostal space mid-clavicular
53
define DVT
formation of a thrombus (blood clot) within the deep veins , which partially or fully obstructs the blood flow
54
List the risk factors for a DVT?
```
THROMBOEMBOLIC RF:
immobilisation
recent surgery
cancer
pregnancy
previous thromboembolism
oral contraceptive pill
recent flight
elderly
obesity
```
```
GENETIC RF:
factor V leiden
protein C or S deficiency
anti phospholipid syndrome
anti thrombin deficiency
```
55
What is virchows triad?
"clot forming" triad
1. blood stasis
2. vessel injury
3. activation of clotting system
56
When should you suspect a DVT?
commonly in the calf or leg
unilateral red, hot swelling
pain along deep venous system
tenderness
+/ oedema, collateral superficial veins
57
What are the differentials for a DVT?
```
cellulitis
rupture of bakers cyst
trauma
chronic venous insufficiency
peripheral vascular disease (acute limb ischaemia)
```
58
Which score is used to assess a DVT?
WELLS SCORE
>/= 2 point -> DVT likely
= 1 point -> DVT unlikely
59
What scores 1 point in the wells score when assessing a DVT?
active cancer (ongoing within 6 months or palliative)
paralysis or recent plaster immobilisation of lower extremity
bedridden for >3 days or major surgery within previous 12 weeks
localised tenderness along distribution of deep venous system
entire leg swollen
calf swelling >3cm larger than asymptomatic side
pitting oedema on symptomatic leg
collateral superficial veins
previous documented DVT
(alternative diagnosis at least as likely as DVT = -2)
60
What are the complications of a DVT?
Pulmonary embolism - thrombus dislodges and travels to lungs
post thrombotic syndrome - chronic venous hypertension causing limb pain, swelling, hyperpigmentation, dermatitis
61
How is a possible DVT initially investigated depending on wells score?
Wells score >/= 2:
1. proximal leg vein ultrasound within 4 hrs
2. if can't be carried out within 4 hrs, D dimer blood sample
3. give 24hr dose of LMWH until ultrasound
Wells score =1:
1. D - dimer blood test taken
2. if D-dimer negative, consider alternative diagnosis
3. if D-dimer positive, do a proximal leg vein ultrasound within 4 hrs -> if not possible, give 24hr lmwh
62
What other possible investigations might be done if first DVT presentation?
thrombophilia testing
cancer screen
antibody testing e.g. protein C/S, antiphospholipid
Chest x-ray
63
How is a diagnosed DVT managed?
1. low molecular weight heparin for 5 days or until INR >2 for 24 hours
2. warfarin for 3 months (if unprovoked, 6 months) - must be started within 24 hrs of diagnosis
64
How is a DVT prevented?
early mobilisation and hydration after surgery
compression stockings
avoid the pill
elevate legs when sitting
65
What is the mechanism of heparin?
binds to anti thrombin resulting in inhibition of factor Xa
66
List the types of embolus causing a pulmonary embolism and each of their risk factors?
1. thrombus formation in distal veins -> same as DVT
2. fat embolus -> long bone fracture
3. air embolus -> during surgery
4. amniotic fluid embolus -> pregnancy
5. tumour embolus -> cancer
6. foreign bodies -> e.g. IVDU, broken catheters, vena cava filters
67
Describe the symptoms of a pulmonary embolism?
pleuritic chest pain
shortness of breath
haemoptysis
68
what are the signs of a pulmonary embolism on examination?
```
sinus tachycardia, tachypnoea
pleural rub
raised JVP
hypoxia
shock
crackles
```
69
What score on the PE wells score indicates a PE?
>/= 4
70
How is a pulmonary embolism treated?
1. 100% oxygen
2. morphine
3. IV access -> fluid bolus
4. LMWH (dalteparin or fondaparinux) for 5 days
5. organise CTPA (+/- ECG to exclude MI, chest x ray)
6. if sats don't rise -> CPAP, nasopharyngeal airway
7. warfarin for 3 months (INR 2-3) - given within 24hrs of PE
(IVC filter and warfarin long term if clotting disorder/ recurrent thrombotic events)
71
What are the main risk factors for lung cancer?
SMOKING !!!
| + asbestos, previous radiotherapy to the chest
72
What are the types of lung cancer and what is the most common?
1. SMALL CELL LUNG CANCER (15%)
aggressive, 90% have mets at presentation, paranoeplastic manifestations as production of ACTH and ADH
2. NON SMALL CELL LUNG CANCER
a. adenocarcinoma (40%)
b. squamous cell carcinoma (35%) - secrete PTH
c. large cell (10%)
d. carcinoid
73
Describe the features of adenocarcinoma of the lung?
most common
peripheral in origin
from mucus cells at the bronchial epithelium
74
Describe the features of squamous cell carcinoma of the lung?
arise in proximal segmental bronchi in the central airways
| grow slowly and locally spread
75
How do lung cancers present?
```
persistent cough
haemoptysis
shortness of breath
recurrent chest infections
weight loss, anorexia
fatigue
finger clubbing
```
+ chest pain -> invasion of pleura
+ hoarseness/ vocal cord palsy -> invasion of recurrent laryngeal nerve
+ Horners syndrome -> invasion of sympathetic chain
+ weakness, parasthesia -> invasion of brachial plexus
+ SVC obstruction
+ pleural effusion
76
How is possible lung cancer diagnosed?
1. Chest x - ray
2. contrast enhanced CT scan
3. CT guided bronchoscopy and biopsy
4. PET scan
77
How is lung cancer managed?
stage 1/2 -> surgical resection via lobectomy or thoracotomy
stage 3/4 -> chemotherapy, radiotherapy
78
How is lung cancer managed if palliative and for supportive care?
pain -> analgesia
breathlessness -> opioids
obstruction -> external beam radiotherapy
pleural effusion -> chest drain
spinal cord compression -> dexamethasone, radiotherapy
support -> refer to lung cancer specialist nurses, district nurses, palliative care team
79
What are the possible causes of pulmonary fibrosis?
1. connective tissue disorders
e. g. RA, sjogrens, systemic sclerosis, SLE
2. occupational exposure -> pneumoconiosis
e. g. asbesto, coal workers, silica
3. medication
e. g. methotrexate, amiodarone, bleomycin
4. inhalation of allergens -> hypersensitivity allergic alveolitis
e. g. farmers lung, pigeons fanciers, mould
5. idiopathic
80
Describe the pathology of pulmonary fibrosis?
1. interstitial lung damage causing inflammation
2. increased fibroblast activity
3. secretes increased collagen and extracellular matrix
4. results in fibrosis of the lung causing decreased compliance
5. = RESTRICTIVE lung disease
81
How does pulmonary fibrosis present?
```
4 D'S
D - dyspnoea
D - dry cough
D - diffuse inspiratory crackles
D - Digital clubbing
```
82
What will spirometry show for pulmonary fibrosis?
restrictive pattern
FEV1 and FVC both reduced
FEV1/FVC ratio increased >0.8
83
Who is at risk of idiopathic pulmonary fibrosis and how do they present?
male, elderly, smoking, dust exposure
4 D's: dyspnoea, dry cough, digital clubbing, diffuse inspiratory crackles
weight loss
84
How is idiopathic pulmonary fibrosis investigated and managed?
1. spirometry - restrictive pattern
2. CT scan - ground glass appearance, honeycombing
3. no treatment to cure, prognosis of 2-5 years (lung transplant to cure)
4. supportive care: oxygen therapy, pulmonary rehab, physiotherapy, vaccinations, smoking cessation
5. anti fibrinolytic e.g. pirfenidone
6. acute exacerbation - prednisolone high dose
85
What is hypersensitivity pneumonitis / extrinsic allergic alveolitis?
type 3 hypersensitivity (non IgE mediated) reaction to inhaled allergens causing widespread inflammation of the small airways
86
what are the risk factors/ types of hypersensitivity pneumonitis?
1. Farmers lung -> mould, agriculture
2. Pigeon fanciers lung -> birds
3. malt workers lung
4. cheese makers lung
+ smoking, lung disease
87
How does hypersensitivity pneumonitis present?
ACUTE: 4-8 hours after exposure
flu like illness + dry cough + dyspnoea
SUBACUTE: more gradual onset
dry cough + dyspnoea + fatigue + anorexia
CHRONIC
4 D's!!! + weight loss
88
How is hypersensitivity pneumonitis investigated?
1. CXR - fibrosis in upper zone
2. CT - ground glass appearance
3. spirometry - restrictive pattern
4. raised ESR/CRP
89
How is hypersensitivity pneumonitis managed?
1. avoid allergen, wear face masks
| 2. oral prednisolone (high dose if acute, low dose if chronic)
90
Describe the occupational causes of pulmonary fibrosis "pneumoconiosis" and how they are managed and investigated?
causes: coal workers lung, silicosis (construction, mining, pottery), asbestosis (asbestos exposure)
present: 4 D's + black sputum
Ix: occupational history, spirometry (restrictive), CXR (ground glass, calcification, nodular fibrosis)
upper zone in silicosis and coal workers, lower zone in asbestosis
Rx: avoid exposure, incurable, smoking cessation, claim compensation
91
What is goodpastures disease?
anti glomerular basement membrane disorder where antibodies are against type IV collagen in the alveoli and glomeruli
92
How does goodpastures disease present?
often young men
RENAL -> AKI -> oedema, reduced urine output, recent UTI
caused by progressive glomerulonephritis
PULMONARY -> cough, haemoptysis, SOB, fever + pulmonary haemorrhage
93
How is goodpastures disease diagnosed?
1. anti GBM antibodies (IgG)
2. kidney tests: urinalysis (proteinuria, haematuria), renal biopsy (glomerulonephritis, IgG staining on immunofluorescence), raised urea and creatinine
3. lung tests: CXR (lower zone pulmonary infiltrates)
94
How is goodpastures treated?
1. oral prednisolone
+ plasmapheresis
+ cyclophosphamide
95
Define wegeners granulomatosis / granulomatosis with polyangitis?
autoimmune condition characterised by **necrotising granulomatous vasculitis**
96
How does granulomatosis with polyangitis present?
UPPER RESP TRACT SYMPTOMS
sinusitis, ear ache, nasal discharge/ nose bleeds, stridor, saddle nose deformity *, conjunctivitis
LOWER RESP TRACT SYMPTOMS
SOB, persistent cough, haemoptysis
GLOMERULONEPHRITIS
oedema, HTN, haematuria
+ fever, weight loss, loss of appetite, arthralgia, weakness
97
How is granulomatosis with polyangitis diagnosed?
1. c Anti Neutrophil Cytoplasmic Antibodies(ANCA) +ve
2. renal biopsy - vasculitis and granulomas
3. urinalysis - haematuria, proteinuria
4. raised ESR
5. CT chest
98
How is granulomatosis with polyangitis treated?
1. IV methylprednisolone for 3 days or oral prednisolone
2. cyclophosphamide used initially to get condition under control
3. methotrexate + azathioprine daily
4. +/- plasma exchange (filter out antibodies)
99
What is pulmonary hypertension?
mean pulmonary artery pressure >25 mmHg at rest with pulmonary capillary wedge pressure <15 mmHg
(disease of small pulmonary arteries characterised by vascular proliferation and remodelling)
100
list the causes of pulmonary hypertension?
```
inherited
connective tissue disorders e.g. CREST
lung disease e.g. COPD
heart disease
amphetamines
```
101
How does pulmonary hypertension present?
dysnpnoea
tricuspid regurgitation murmur
pulmonary regurgitation murmur (GRAHAM STEEL)
R sided heart failure
102
How is pulmonary hypertension managed?
1. calcium channel blocker e.g. amlodipine
2. anti coagulant e.g. warfarin
3. furosemide for oedema
103
Define bronchiectasis?
permanent dilatation and thickening of the airways due to recurrent infection and inflammation
(failure of mucociliary clearance and impaired immune function)
104
How is bronchiectasis caused?
organisms: staph aureus, h.influenzae, pseudomonas aeruginosa
1. POST INFECTION e.g. measles, pneumonia
2. GENETIC e.g. cystic fibrosis, ciliary dyskinesia, A1ATD
3. CONNECTIVE TISSUE DISORDER e.g. RA, sjogrens
4. iMMUNODEFICIENCY e.g. HIV
105
Describe the symptoms of bronchiectasis
chronic daily cough with excessive sputum (green/ yellow)
recurrent infections
weight loss, fatigue, dyspnoea
106
what are the signs of bronchiectasis on examination?
inspiratory coarse crackles
clubbing
high pitched bronchi
107
How is bronchiectasis investigated?
1. sputum culture - obtain in acute exacerbation
2. CT - thickened, dilated airways
3. spirometry - obstructive FEV:FVC <0.7, FEV1 <0.8
108
How is bronchiectasis managed?
CONSERVATIVE
chest physiotherapy for airway clearance
exercise e.g. inspiratory muscle training
optimal nutrition
LONG TERM MEDICAL TREATMENT
bronchodilator inhaler
hypertonic saline inhaler
prophylactic antibiotics if >3 acute exacerbations
ACUTE EXACERBATION
oral or iV antibiotics e.g. amoxicillin, doxycycline, clarithromycin for 7-14 days - depending on sputum culture result
nebulised tobramycin for pseudomonas infection
109
What causes acute respiratory distress syndrome?
```
infection e.g. sepsis, pneumonia
massive blood transfusion
trauma
acute pancreatitis
CABG
```
110
What is the criteria for acute respiratory distress syndrome?
1. acute onset
2. BILATERAL pulmonary oedema on chest x-ray
3. non cardiogenic
4. PO2 <40 kPa on PEEP/CPAP (hypoxia despite oxygen therapy)
111
How is ARDS managed?
1. transfer to ITU
2. oxygenation/ ventilation
3. organ support
4. treat cause
112
What is the difference between type 1 and type 2 respiratory failure?
type 1 = failure of lungs and heart to provide adequate oxygen to meet metabolic needs -> HYPOXIA
type 2 = failure of lungs to eliminate adequate CO2 -> HYPOXIA AND HYPERCAPNIA
113
How does empyema develop?
simple pleural effusion with clear sterile fluid -> fluid gets infected -> pus in pleural space
114
What are the risk factors for an empyema developing?
IVDU
diabetics
alcohol abuse
GORD
115
what features of the aspirate of the pleural fluid in an effusion suggests empyema?
turbid colour
pH <7.2
low glucose
high LDH
116
What is Meigs syndrome?
benign ovarian fibroma + pleural effusion + ascites
117
List the causes of upper zone fibrosis on CT?
```
C - coal workers pneumoconiosis
H - histiocytosis
A - ankylosing spondylitis
R - radiation
T - TB
S - sarcoidosis, silicosis
```
118
Define sarcoidosis
chronic granulomatous inflammation disorder characterised by accumulation of lymphocytes and macrophages In the lungs and other organs
119
describe the features of sarcoidosis
1. bilateral hilar lymphadenopathy **
2. 4 D's!!!**
3. eye - photophobia, red painful eye, blurred
4. skin - erythema nodosum (acute)
5. MSK - polyarthralgia (acute), fever, chronic fatigue, weight loss
120
How does sarcoidosis acutely present?
fever
arthralgia
erythema nodosum
4 D's
121
How is sarcoidosis investigated?
1. chest x ray - upper zone fibrosis (stage 4) and bilateral hilar lymphadenopathy (stage 1)
2. spirometry - restrictive
3. hypercalcaemia
4. raised ACE levels
5. biopsy - non caseating granuloma
+ ESR raised, FBC (anaemia), U&E,
122
list other causes of bilateral hilarity lymphadenopathy
TB
lymphoma
non small cell lung cancer
123
How is sarcoidosis managed?
for stage 2/3 lung disease -> oral or inhaled corticosteroid +/- methotrexate
for skin -> topical corticosteroid
124
list side effects of long term steroid use
```
thin skin
easy bruising
osteoporosis
weight Gain
hyperglycaemia
skin atrophy
```
125
what causes lower zone fibrosis?
idiopathic pulmonary fibrosis
asbestosis
drug induced e.g. amiodarone
most connective tissue disorders (not ank spon!!)
126
How is idiopathic pulmonary fibrosis investigated?
CT - ground glass appearance, lower zone fibrosis
spirometry - restrictive pattern
transfer factor reduced
127
what is a malignant mesothelioma and how is it caused?
malignant tumour of mesoepithelial cells
| caused by asbestos exposure - can claim compensation
128
what other conditions can small cell lung cancer cause?
hyponatraemia - due to ADH
Cushings syndrome - due to ACTH
bilateral adrenal hyperplasia
Lambert eaton syndrome
129
what is the MRCP dyspnoea scale?
1. breathless on strenuous exercise
2. SOB when hurrying
3. stop for breath when walking
4. stop after 100m level ground
5. SOB on dressing
130
what can be used in smoking cessation?
1. nicotine replacement therapy e.g. patches, gum, lozenge, spray SE= nausea, flu, headaches
2. varenidine = nicotinic receptor partial agonist, 12 week course SE= nausea
3. bupropion= norepinephrine and dopamine reuptake inhibitor and nicotinic antagonist
131
which antibiotic is prescribed for legionella?
ciprofloxacin / clarithromycin
132
when would you suspect empyema?
= pus in pleural space -> a slow to respond pneumonia
133
what would you find on aspiration of empyema?
turbid effusion
low pH
high LDH
low glucose
134
what might the pleural fluid findings suggest in pleural effusion?
* low glucose: rheumatoid arthritis, tuberculosis
* raised amylase: pancreatitis, oesophageal perforation
* heavy blood staining: mesothelioma, pulmonary embolism, tuberculosis
135
If a PE wells score >4, what should be next steps?
immediate computed tomography pulmonary angiogram (CTPA).
| If there is a delay in getting the CTPA then give low-molecular-weight heparin until the scan is performed.
136
How is a PE diagnosed?
CTPA (computed tomography pulmonary angiogram)
use the PESI (pulmonary embolism severity index) score
137
which tests should you consider before giving LMWH?
```
FBC - check platelets
UandE
LFT
clotting
weight
```
138
list the complications of a PE?
ARDS
pulmonary oedema
AF
pulmonary hypertension
139
when is long term oxygen therapy needed in COPD?
if peripheral oedema or polycythaemia
140
which oxygen therapy is best in COPD patients?
27% venturi mask at 4L /min
| aim oxygen sats 88-92%
141
list the features of churg Strauss?
P-ANCA
Asthma
Vasculitis
Eosinophilia
142
How is sleep apnoea managed?
1. weight loss
| 2. CPAP
143
What are the symptoms of smoke inhalation?
```
harsh cough
stridor
tachypnoea
singed nasal hairs
hoarse voice
reduced chest expansion
```
144
What electrolyte disturbances does legionella cause?
hyponatraemia
| hypokalaemia
145
What are the signs on ECG of pulmonary embolism?
sinus tachycardia
| large S wave in V1, large Q wave in V3, inverted T wave in V3
146
What is the work up for suspected PE?
1. chest x ray (wedge infarct)
2. CTPA** / VQ scan - confirms diagnosis
3. ECG
147
How are the number of pack years calculated?
pack years = (no. of cigarettes a day / 20) x no. of years smoked
148
How does salbutamol work?
stimulates beta 2 receptors on bronchial smooth muscle to stimulate sympathetic activity and relax bronchial smooth muscle
149
Why is TB on the rise?
```
poor socio-economic conditions
overcrowding
immunosuppression
increased immigration from high risk countries
antibiotic resistance
```
150
What are the complications of bronchiectasis?
recurrent infections and pneumonia
respiratory failure
cor pulmonale
pneumothorax
151
Which score is used for obstructive sleep apnoea
Epworth sleepiness questionnaire
152
What are the risk factors for obstructive sleep apnoea?
obesity
acromegaly
enlarged tonsils
alcohol
153
How is sleep apnoea diagnosed?
sleep studies
