Respiratory Flashcards
Define asbestosis.
Long-term inflammation and scarring of the lungs caused by inhalation of asbestos fibres.
Define mesothelioma.
Aggressive tumour of mesothelial cells that usually occurs in the pleura (90%), and sometimes in peritoneum, pericardium or testes.
What are the presenting symptoms of asbestosis?
o Progressive dyspnoea
What are the presenting symptoms of mesothelioma?
o Most common symptoms = SOB, Chest pain (dull, diffuse, developing), Weight loss
o Fatigue
o Fever
o Night sweats
o Bone pain
o Abdominal pain
o Sometimes Bloody sputum – if tumour invades blood vessel
What are the clinical signs of mesothelioma on examination?
o Occasional palpable chest wall mass
o Finger clubbing - due to underlying asbestosis (pulmonary fibrosis)
o Recurrent pleural effusions
o Signs of metastases = Lymphadenopathy, Hepatomegaly, Bone tenderness
o Abdominal pain/obstruction (peritoneal malignant mesothelioma)
o Pneumothorax - rare
What are the appropriate investigations for asbestosis?
o Mainly off history and exam
o CXR = Reticular-nodular shadowing +/- pleural plaques
What are the appropriate investigations for mesothelioma?
o CXR/CT = Pleural thickening/effusion, Bloody pleural fluid, May show pleural mass and rib destruction
o MRI and PET
o Pleural fluid cytology
o Pleural biopsy = Diagnosis is made on histology, usually following a thoracoscopy (pleural biopsy) - often done post-mortem -> Biopsy of the tumour can be immunostained with a stain that reacts with calretinin
What are the clinical signs of abestosis on examination?
o Clubbing
o Fine end-inspiratory crackles
Define aspergillus lung disease.
Lung disease associated with Aspergillus fungal infection.
o 5 different ways this group of fungi can affect the lungs:
- Asthma = Type I hypersensitivity (atopic) reaction to fungal spores
- Allergic bronchopulmonary aspergillosis (ABPA) = Type I and Type III hypersensitivity reactions to Aspergillus fumigatus
- Aspergilloma = Fungus ball within a pre-existing cavity (often caused by TB or sarcoidosis)
- Invasive aspergillosis
- Extrinsic allergic alveolitis (EAA) = Sensitivity to Aspergillus clavatus (‘malt worker’s lungs’)
What are the presenting symptoms of aspergillus lung disease?
o Aspergilloma = Mostly asymptomatic - can cause cough, haemoptysis (potentially massive), lethargy, weight loss
o ABPA = Difficult to control asthma, Recurrent episodes of pneumonia with wheeze, cough, sputum, dyspnoea, fever and malaise
o Invasive Aspergillosis = Dyspnoea, Rapid deterioration, Septic picture
What are the clinical signs of aspergillus lung disease on examination?
o Tracheal deviation with very large aspergillomas
o Dullness in affected lung
o Reduced breath sounds
o Wheeze (in ABPA)
o Cyanosis (possible in invasive aspergillosis)
What are the appropriate investigations for aspergillus lung disease?
o Aspergilloma
- CXR = May show a round mass with a crescent of air around it, usually found in the upper lobes - CT or MRI if CXR is unclear
- Strongly positive serum precipitins
- Aspergillus skin test = positive in 30%
o ABPA
- Immediate skin test reactivity to Aspergillus antigens
- Aspergillus-specific IgE radioallergosorbent test
- Bloods = Eosinophilia, Raised total serum IgE, Raised specific serum IgE and IgG to A. fumigatus
o Sputum Culture
- CXR = Transient patchy shadows, Segmental collapse or consolidation, Distended mucous-filled bronchi, Signs of complications (fibrosis in upper lobes or bronchiectasis)
- CT = Lung infiltrates, Central bronchiectasis
- Lung Function Tests = Reversible airflow limitation, Reduced lung volumes/gas transfer
o Invasive Aspergillosis
- Cultures from bronchoalveolar lavage/sputumand Histological examination
- CT = Nodules surrounded by a ground-glass appearance (halo sign) due to haemorrhage into the tissue surrounding the fungal invasion
Define bronchiectasis.
Lung airway disease characterised by chronic bronchial dilation as well as impaired mucociliary clearance and frequent bacterial infections.
What are the risk factors/causes of bronchiectasis?
o Idiopathic (50%)
o Congenital = CF, Young’s syndrome, Primary ciliary dyskinesia, Kartagener’s syndrome, Alpha-1 antitrypsin deficiency
o Post-infection - e.g. pneumonia, whooping cough, TB, measles, pertussis, bronchiolitis
o Host immunodeficiency = Hypogammaglobulinaemia, HIV
o Obstruction of bronchi - e.g. foreign body, tumour, enlarged lymph nodes
o GORD
o Inflammatory disorders - e.g. rheumatoid arthritis, UC
o Allergic bronchopulmonary aspergillosis (ABPA)
- Presents in childhood
What are the presenting symptoms of bronchiectasis?
o Persistent cough with copious purulent sputum - worsened by lying flat
o Intermittent haemoptysis
o Breathlessness
o Chest pain
o Malaise
o Fever - especially if recurrent episodes
o Weight loss
o Symptoms usually begin after an acute respiratory illness
o All symptoms worsen during acute exacerbations
What are the clinical signs of bronchiectasis on examination?
o Clubbing
o Coarse inspiratory crackles - usually at lung bases - shift with coughing
o Wheeze = high-pitched inspiratory squeaks
What are the appropriate investigations for bronchiectasis?
o Sputum = Culture and sensitivity
o CXR = Dilated bronchi, Fibrosis, Atelectasis, Pneumonic consolidations - can be normal
o High-Resolution CT = Gold Standard - Helps assess extent and distribution of disease, Shows dilated bronchi with thickened walls
o Bronchography - rarely used
o Spirometry usually shows obstructive image = should assess reversibility
o Others = Sweat electrolytes (for cystic fibrosis), Serum Ig, Mucociliary clearance study, Aspergillus precipitins or skin-prick test
What is the management plan for bronchiectasis?
o Postural drainage should be performed twice daily for sputum and mucus clearance - reduce frequency of acute exacerbations and aid recovery
o Treat acute exacerbations with IV antibiotics - Prophylactic antibiotics should be considered in patients with frequent exacerbations (> 3/year)
o Bronchodilators = nebulised salbutamol - considered in patients with responsive disease e.g. asthma, COPS
o Inhaled Corticosteroids = Useful for ABPA
o Maintain hydration
o Flu vaccination
o Surgical = Localised resection, Lung or Heart-lung transplantation (localised disease or to control severe haemoptysis)
o Bronchial artery embolisation = If life-threatening haemoptysis due to bronchiectasis
What are the possible complications of bronchiectasis?
o Life-threatening haemoptysis
o Pneumonia
o Pneumothorax
o Persistent infections
o Empyema
o Respiratory failure
o Cor pulmonale
o Multi-organ abscesses
o Amyloidosis
Define extrinsic allergic alveolitis.
Interstitial inflammatory disease of the distal gas-exchanging parts of the lung caused by inhalation of organic dusts.
- Farmer’s Lung = mouldy hay containing thermophilic actinomycetes
- Pigeon Fancier’s Lung = blood on bird feathers and excreta
- Maltworker’s Lung = barley or maltlings containing Aspergillus clavatus
- Bagassosis or Sugar Worker’s Lung
What are the presenting symptoms of extrinsic allergic alveolitis?
o Acute = Present 4-12 hrs after exposure
- Reversible episodes of = Dry cough, Dyspnoea, Malaise, Fever, Myalgia, Wheeze and productive cough may develop if high-level of repeated exposure
o Chronic
- Slowly increasing breathlessness, Decreased exercise tolerance, Weight loss, Exposure is usually chronic, low-level and there may be no history of previous acute episodes
o History is vital to diagnosis
What are the clinical signs of extrinsic allergic alveolitis on examination?
o Acute = Rapid shallow breathing, Pyrexia, Inspiratory crackles
o Chronic = Fine inspiratory crackles, Clubbing if severe
What are the appropriate investigations for extrinsic allergic alveolitis?
o Bloods = FBC (neutrophilia, lymphopenia), ESR, ABG
o Serology = IgG to fungal or avian antigens - not diagnostic
o CXR = Often normal in acute episodes, Fibrosis may be seen in chronic cases (upper zone mottling/consolidation), Hilar lymphadenopathy
o CT = Detects early changes, May show patchy ‘ground glass’ shadowing and nodules and extensive fibrosis in chronic condition
o Pulmonary Function Tests = Reversible restrictive defect (low FEV1, low FVC), Preserved or increased FEV1/FVC ratio, Reduced total lung capacity, Reduced gas transfer during acute attacks
o Bronchoalveolar Lavage = Increased lymphocytes and mast cells
o Lung biopsy
Define idiopathic pulmonary fibrosis.
Chronic inflammation of the lung resulting in fibrosis of the alveoli and interstitium, due to an unknown mechanism causing excess collagen in connective and interstitial tissue causing thickening.
What are the risk factors for idiopathic pulmonary fibrosis?
o Age
o Male
o Smoking
o Occupational exposure to metal or wood
o Chronic microaspiration
o Animal and vegetable dusts
What are the presenting symptoms of idiopathic pulmonary fibrosis?
o Gradual-onset, progressive dyspnoea on exertion
o Dry irritating cough
o No wheeze
o Symptoms may be preceded by a viral-type illness
o Fatigue and weight loss are common
What are the clinical signs of idiopathic pulmonary fibrosis?
o Clubbing (50%)
o Bibasal fine late inspiratory crackles
o Cyanosis
o Signs of right heart failure in advanced stages of disease
What are the appropriate investigations for idiopathic pulmonary fibrosis?
o Bloods = Raised CRP and immunoglobulins, ABG (normal in early disease)
o Serology = ANA and Rheumatoid Factor (1/3 of patients)
o CXR = Usually normal at presentation
- Early disease = Ground glass shadowing
- Later stage disease = Bilateral lower zone reticulonodular shadowing, Signs of Cor Pulmonale and Honeycombing
o CT= o Pulmonary Function Tests
Restrictive features (reduced FEV1 and FVC, with preserved or increased FEV1/FVC), Decreased lung volumes, Decreased lung compliance, Decreased total lung capacity
o Bronchoalveolar Lavage - exclude infections and malignancy
o Lung Biopsy = Gold Standard for diagnosis but not always needed
o Echocardiography - Check for pulmonary hypertension
Define obstructive sleep apnoea.
A disease characterised by recurrent prolapse of the pharyngeal airway and apnoea (cessation of airflow for > 10 s) during sleep, followed by partial arousal from sleep.
What are the risk factors for obstructive sleep apnoea?
o Weight gain - soft tissue in neck area
o Surgical swelling
o Smoking
o Alcohol
o Sedative use
o Enlarged tonsils and adenoids in children
o Macroglossia
o Marfan’s syndrome
o Craniofacial abnormalities
What are the presenting symptoms of obstructive sleep apnoea?
o Excessive daytime sleepiness
o Unrefreshing or restless sleep
o Morning headaches
o Dry mouth
o Difficulty concentration
o Irritability and mood changes, decreased libido and cognitive performance
o Partner reporting loud snoring, nocturnal apnoeic episodes or nocturnal choking
What are the clinical signs of obstructive sleep apnoea on examination?
o Large tongue
o Enlarged tonsils
o Long or thick uvula
o Retrognathia (pulled back jaws)
o Neck circumference = more than 42 cm in males and more than 40 cm in females
o Obesity
o Hypertension
What are the appropriate investigations for obstructive sleep apnoea?
o Simple studies = Pulse oximetry, Video recording
o Sleep Study (polysomnography) = Monitor overnight with polysomnogram, Monitor airflow, respiratory effort, pulse oximetry and heart rate and snoring and movement - Occurrence of 15 or more episodes of apnoea or hypopnoea during 1 hour of sleep indicates significant sleep apnoea
o Bloods = TFTs, ABG
Define pneumoconiosis.
Fibrosing interstitial lung disease caused by chronic inhalation of mineral dusts.
- Simple = Coalworker’s pneumoconiosis or silicosis (symptom-free) - due to inhalation of coal dust particles over 15-20 yrs
- Complicated = Pneumoconiosis resulting in loss of lung function
- Asbestosis = Pneumoconiosis in which diffuse parenchymal lung fibrosis occurs as a result of prolonged exposure to asbestos
What are the risk factors for pneumoconiosis?
o Inhalation of particles of Coal dust, Silica or Asbestos - Occupational exposure (coal mining, quarrying, iron and steel foundries, stone cutting, sandblasting, insulation industry, plumbers, ship builders)
o Co-factors such as smoking and TB also contribute
o Co-existence with chronic bronchitis
What are the presenting symptoms of pneumoconiosis?
o Occupational history is very important
o Asymptomatic - picked up on routine CXR
o Insidious onset shortness of breath
o Dry cough
o Black sputum (melanoptysis) - produced occasionally in coalworker’s pneumoconiosis
o Pleuritic chest pain (due to acute asbestos pleurisy) - in patients exposed to asbestos
What are the clinical signs of pneumoconiosis on examination?
o Examination may be normal
o Coalworker’s pneumoconiosis and silicosis = Decreased breath sounds
o Asbestosis = End-inspiratory crackles, Clubbing
o Signs of pleural effusion or right heart failure (cor pulmonale)
What are the appropriate investigations for pneumoconiosis?
o CXR = Simple (micronodular mottling), complicated (nodular opacities in upper lobes, micronodular shadowing, eggshell calcification of hilar lymph nodes (characteristic of silicosis), bilateral lower zone reticulonodular shadowing and pleural plaques (in asbestosis))
o CT Scan = Fibrotic changes can be visualised early
o Bronchoscopy = Allows visualisation and bronchoalveolar lavage
o Lung Function Tests = Restrictive pattern
