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3B General Care > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Types of Pneumonia

A

Community acquired
Hospital acquired
aspiration
immunocompromised

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2
Q

Community acquired pneumonia

A

primary or secondary to underlying cause
most common: streptococcus pneumoniae
Also: staphylococcus aureus, legionella, moraxella catarrhalis and chlamydia
viruses = 15%
may be complicated by MRSA

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3
Q

Hospital acquired pneumonia

A

acquired after >48hrs in hospital
most commonly gram negative enterobacteria or staph. aureus
also psuedomonas, klebsiella, bacteriordes and clostridia

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4
Q

aspiration pneumonia

A 
stroke, myasthenia, bulbar palsies, decreased conciousness (e.g. post ictal/drunk)
oesophageal disease (achalasia/reflux) or poor dental hygiene
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5
Q

Immunocompromised patient

A

strep pneumoniae, h. influenzae, staph. aureus, Mycoplasma catarrhalis, mycoplasma pneumoniae, gram negative bacilli, pneumocystis jirovecii
fungi, viruses (CMV, HSV) and mycobacteria

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6
Q

Symptoms of pneumonia

A 
fever
rigors
malaise
anorexia 
dyspnoea
cough 
purulent sputum 
haemoptysis
pleuritic pain
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7
Q

Signs of pneumonia

A 
pyrexia
cyanosis
confusion 
tachypnoea
tachycardia 
hypotension
signs of consolidation - diminished expansion, dull percussion, increased vocal fremitus/ resonance, bronchial breathing)
pleural rub
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8
Q

Pneumonia investigations

A

CXR - lobar infiltrates, cavitation or pleural effusion
SpO2- less than 92% = severe –> ABG
FBC, U&E, LFT, CRP, blood cultures
Sputum MC&S- PCR if possible atypical organism
Pleural fluid aspiration
Bronchoscopy
Bronchoalveolar lavage- immunocompromised or ITU

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9
Q

Pneumonia Severity Score

A

CURB 65

  • C = confusion
  • U = urea >7
  • R = resp rate >30/min
  • B = BP <90 systolic
  • 65 = age over 65

0-1 treat at home
2- hospital therapy
3- may need ITU

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10
Q

Management of Pneumonia

A 
Abx
Oxygen 
IV fluids 
VTE prophylaxis
Analgesia if pleurisy
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11
Q

Complications of pneumonia

A 
pleural effusion 
empyema 
lung abscess
respiratory failure 
septicaemia 
brain abscess
pericarditis
myocarditis
cholestatic jaundice
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12
Q

Treatment of mild, community acquired pneumonia

Strep. pneumoniae
Haemophilus influenzae

A

Oral amoxicillin 500mg- 1g/ 8hr
clarithromycin 500mg/12hr
doxycycline 200mg loading dose then 100mg/day

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13
Q

Treatment Moderate community acquired pneumonia

Strep pneumoniae
h. influenzae
mycoplasma pneumoniae

A

oral amoxicillin 500mg-1g/8hrs + clarithromycin 500mg/doxycycline 200mg loading then 100mg/day

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14
Q

Treatment of severe community acquired pneumonia

Strep pneumoniae
h. influenzae
mycoplasma pneumoniae

A

co-amoxiclav 1.2g/8hr IV
or
cephalosporin (cefuroxime) IV + clarithromycin IV
add flucloxacillin ± rifampacin if staph suspected
vancomycin or teicoplanin if MRSA

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15
Q

Treatment of Atypical community acquired pneumonia

legionella pneumophilia
chlamydia species
pneumocystis jiroveci

A

legionella -
fluroquinolone with clarithromycin or rifampicin if severe

chlamydia - tetracycline
pneumocystitis - high dose trimoxazole

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16
Q

Treatment of hospital acquired pneumonia

Gram negative bacilli
psuedomonas
anaerobes

A

Aminoglycoside (gentamicin) IV + antipseudomonal penicillin (ticcarcillin)IV or 3rd gen cephalosporin IV (cefotaxim)

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17
Q

Treatment of aspiration pneumonia

streptococcus pneumoniae
anaerobes

A

cephalosporin IV + metronidazole IV

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18
Q

Treatment of pneumonia in neutropenic patients

  • gram +ve cocci
  • gram -ve bacilli
A

Aminoglycoside (Gentamicin) IV + antipseudomonal penicillin (ticarcillin) or 3rd gen cephalosporin (cefotaxime)

consider antifungals after 48hrs if not improving

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19
Q

Pneumococcal pneumonia

A

commoner in the elderly, alcoholics, post-splenectomy, immunosuppressed and chronic heart failure or pre-existing lung failure

Treat- amoxicillin, benzylpenicillin or cephalosporins

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20
Q

Staphylococcal pneumonia

A

complicate influenza infection
young/ elderly, IVDU or underlying disease
bilateral cavitating broncho-pneumonia

Treat- flucloxacillin ±rifampacin
MRSA - consider vancomycin

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21
Q

Psuedomonas pneumonia

A

common in bronchiectasis and CF
causes HAP - ITU/ post-op

Treatment- anti-pseudomonal penicillin (ticarcillin/pipericillin).ceftazimide, meropenem or ciprofloxacin +aminoglycoside (gentaminc/ fluroquinolone)

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22
Q

Klebsiella pneumonia

A 
rare
elderly, diabetics, alcoholics
cavitating pneumonia of the upper lobes 
often drug resistance 
Tret - cefotaxime or imipenem
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23
Q

Mycoplasma pneumonia

A 
occurs in epidemics every 4ish years 
flu-like symptoms --> dry cough 
CXR- reticular nodular shadowing
Diagnosis - Sputum PCR/ serology 
Complications - skin rash (erythema multiforme), steven-johnson syndrome, meningoencephalitis or myelitis, GBS

Treat- clarithromycin/doxycline/fluroquinolone

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24
Q

Legionella pneumonia

  • colonises water tanks kept <60C
A

flu like symptoms proceed dry cough and dyspnoea
extra-pulmonary - anorexia, D&V, hepatitis, renal failure, confusion and coma

CXR- bi-basal consolidation
Investigations- lymphopenia, hyponatraemia, deranged LFTS, haematuria

Dx- legionella antigen urine/ culture

Rx- fluroquinolone (2/3 weeks) or clarithromycin

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25
Q

Chlamydophila pneumoniae

A

commonest chlamydial infection
person-to-person spread with biphasic illness
- pharyngitis, hoarseness, otitis followed by pneumonia

Dx- chlamydophilia complement fixation fests, PCR invasive samples

Rx- doxycycline or clarithromycin

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26
Q

Chlamydiophila psittaci

causes psittacosis - ornthosis from infected birds (esp. parrots)

A

Sx- headache, fever, dry cough, lethargy, arthralgia, anorexia and D&V
CXR- patchy consolidation
Dx- chlamydophila serology

x- doxycyline or clarithromycin

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27
Q

Viral pneumonia

A

commonest cause- influenza, could also be measles, CMV or varicella zoster

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28
Q

Pneumocystis pneumonia

PCP

A

immunosuppressed
dry cough, exertional dyspnoea, low PaO2, fever, bilateral crepitations
CXR- normal or bilateral perihilar interstitial shadowing

Dx- visualisation - visualisation in sputum, broncho-alveolar lavage or lung biospy

Rx- high dose co-trimoxazole or pentamidine for 2-3 weeks
steroids if severe hypoxaemia

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29
Q

Complications of pneumonia

respiratory failure

A

Type 1 respiratory failure common
treat with high flow oxygen
check ABGs often

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30
Q

Complications of pneumonia

hypotension

A

combination of dehydration and vasodilatation due to sepsis

IV fluid challenges 250ml boluses

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31
Q

Complications of pneumonia

atrial fibrillation

A

common - particularly in the elderly
usually resolves with treatment of pneumonia
B-blockers of digoxin may be required to slow ventricular response rate in the short term

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32
Q

Complications of pneumonia

pleural effusion

A

Inflammation of the pleura by adjacent pneymona may cause fluid exudation into pleural space

if it accumulates quicker than it gets reabsorbed –> pleural effusion
Drain if large

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33
Q

Complications of pneumonia

empyema

A

pus in the pleural space
suspect in pts with resolving pneumonia with recurrent fever

CXR- indicates pleural fusion
Pleural fluid aspirate is typically yellow and turbid with a low ph, low glucose and raised LDH

Rx- drain with a chest drain

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34
Q

Complications of pneumonia

Lung abscess

Causes

A

cavitating, suppurative infection within the lung

  • inadequately treated pneumonia
  • aspiration (alcohol/obstruction/bulbar palsy)
  • bronchial obstruction (tumour/ FB)
  • pulmonary infarction
  • septic emboli (scepticaemia, R heart endocarditis, IVDU)
  • subphrenic or hepatic abscess
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35
Q

Complications of pneumonia

Lung abscess

Clinical features

A 
swinging fever
cough 
purulent, foul-smelling sputum
pleuritic chest pain
haemoptysis
malaise 
weight loss

–> finger clubbing, anaemia, crepitations, empyema

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36
Q

Complications of pneumonia

Lung abscess

Tests

A

Blood- FBC (anaemia, neutrophilia), EXR, CRP, blood culutres
Sputum microscopy, culture and cutology
CXR- walled cavity, often with a fluid level

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37
Q

Complications of pneumonia

Lung abscess

Treatment

A

Abx as indicated by sensitivities
Continue until healed (4-6 weeks)
Postural drainage
Repeated aspiration, antibiotic instillation or surgical excision may be necessary

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38
Q

Complications of pneumonia

Septicaemia

A

result of bacterial spread from the ung parenchyma into the blood streat
metastatic infection - e.g. infective endocarditis or meningitis
Rx- IV abx

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39
Q

Complications of pneumonia

Jaundice

A

usually cholestatic

may be due to septic or secondary to antibiotic therapy (Esp flucloxacillin or co–amoxiclav)

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40
Q

Bronchiectasis

pathology

A

chronic infection of bronchi and bronchioles leading to permanent dilatation of these airways

Main organisms - h. influenzae, strep. pneumoniae, staph. aureus, pseudomonas aeruinosa

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41
Q

Causes of bronchiectasis

A

congenital - CF, Young’s syndrome, primary ciliary dyskinesia, Kartagner’s syndrome

Post infection - measles, pertussis, bronchiolitis, pneumonia, TB, HIV

Other - bronchial obstruction, allergic bronchopulmonary aspergillosis, hypogammaglobulinaemia, rheumatoid arthritis, UC, idiopathic

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42
Q

Clinical features of bronchiectasis

A

symptoms- persistent cough, copious purulent sputum, intermittent haemoptysis

Signs- finger clubbing, coarse inspiratory crepitations, wheeze

Complications - pneumonia, pleural effusions, pneumothorax, haemoptysis, cerebral abscess, amyloidosis

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43
Q

Tests for Bronchiectasis

A

Sputum culture
CXR- cystic shadows, thickened bronchialwalls (tramline and ring shadows)
Spirometry - obstructive pattern
Bronchoscopy

Others- serum immunoglobilines, CF sweat teast, aspergillus precipitins or skin prick tests

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44
Q

Management of bronchiectasis

A

Postual drainage 2x day- chest physio my aid sputum expectoration and mucous drainage
Antibiotics
Bronchodilators e.g. nebulised salbutamol
Cortio-steroids
Surgery in localised disease or to control severe haemoptysis

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45
Q

Pathology of CF

A

commonest life-threatening autosomal recessive condition
Cl- channel defect leads to a combination of defective chloride secretion and increased sodium absorption across airway epithelium
predisposes lung to chronic pulmonary infections and bronchiectasis

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46
Q

Neonate CF

Clinical features

A

failure to thrive
meconium ileus
rectal prolapse

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47
Q

Clinical features of CF

Children and young adults

A

Resp- cough, wheeze, recurrent infections, bronchiectasis, pneumothorax, haemoptysis, respiratory failure, cor pulmonale

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

Other - male infertility, osteoporosis, arthritis, vasculitis, nasal polyps, sinusitis, hypertrophic pulmonary osteoarthroapthy

Signs - finger clubbing, bilateral coase crackles

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48
Q

Diagnosis of CF

A

Sweat test- sweat sodium and chloride levels >60mmol
Genetics
Fecal elastase

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49
Q

How does aspergillus affect the lungs?

A
  1. Asthma
  2. Allergic bronchopulmonary aspergillosis
  3. Aspergilloma
  4. Invasive aspergillosis
  5. Extrinsic allergic alveolitis
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50
Q

Aspergillus asthma

A

type I hypersensitivity (atopic)reaction to fungal spores

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51
Q

Aspergillus allergic bronchopulmonary aspergillosis

A

type I and type III hypersensitivities
early - bronchoconstriction
late- inflammation persists -> permanent damage - bronchiectasis

Sx- wheeze, cough, sputum, dyspnoea and recurrent pneumonia

CXR- transient segmental collapse or consolidation, bronchiectasis
Rx- prednisolone acute- high dose, maintenance - low dose ± itraconazole ± bronchodilators

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52
Q

ASpergilloma (myectoma)

A

Fungal ball within a pre-existing cavity e.g. TB/ sarcoid
- asymptomatic may cause cough, haemoptysis, lethary ± weight loss

CXR- round opacity within a cavity, usually apical
surgical excision or local instillation of amphotericin

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53
Q

Extrinsic allergic alveolitis

A

sensitivity to aspergillus clavatus - malt workers lunf

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54
Q

Lung cancer

risk factors

A 
cigarette smoking 
asbestos
chromium 
arsenic
iron oxides
radiation
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55
Q

Histology of lung cancers

A 
35% squamous 
27% adenocarcinoma 
20% small oat cell 
10% large cll 
alveolar cell carcinoma is very rare

clinically most important differentiation is small-cell or non-small cell

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56
Q

Symptoms of Lung cancer

A 
Cough
haemoptysis
dyspnoea
chest pain 
recurrent or slow resolving pneumonia
lethargy 
anorexia 
weigh loss
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57
Q

Signs of lung cancer

A 
cachexia
anaemia 
clubbing 
hypertrophic pulmonary osteoarthropathy --> wrist pain 
supraclavicular or axillary nodes

Metasteses- bone tenderness, hepatomegaly, confusion fits, focal CNS signs, cerebellar syndrome, proximal myopathy, peripheral neuropathy

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58
Q

Complications of lung cancer

local

A 
recurrent laryngeal nerve palsy 
phrenic nerve palsy 
SVC obstruction 
Horner's syndrome (Pancoast tumour)
rib erosion 
pericarditis
AF
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59
Q

Complications of lung cancer

metastatic

A 
brain
bone - pain, anaemia, high Ca2+
liver
adrenals- Addison's
Endocrine- ectopic hormone secretion (e.g. SIADH and ACTH (Cushings) (small cell tumours) or raised PTH (squamous cell tumours)
60
Q

Complications of lung cancer

non-metastatic neurological

A 
confusion 
fits
cerebellar syndrome 
proximal myopathy
neuropathy
polymyositis 
Lambert-Eaton syndrome
61
Q

Other complications of lung cancer

A 
clubbing 
hypertrophic pulmonary osteoarthropathy 
dermatomyositis 
acanthosis nigricans 
thrombophlebitis migrans
62
Q

Tests for lung cancer

A 
Cytology - sputum and pleural fluid 
CXR - perihilar nodule, hilar enlargement, consolidation, lung collapse, effusion, bony secondary 
Fine needle aspiration or biopsy 
Bronchoscopy 
PET/CT 
Radionuclide bone scan
Lung function tests
63
Q

Treatment of non-small cell lung cancer tumours

A
  1. Excision
  2. curative radiotherapy
  3. Chemoradiotherapy
    immunological treatment options include cetuximab (monoclonal antibody that targets epidermal growth factor receptors)
64
Q

Treatment of small cell lung cancer tumours

A

nearly always disseminated at presentation
may respond to chemotherapy but invariably relapse
- palliation
- radiation for bronchial obstruction, SVCO, haemoptysis, bone pain and cerebral mets

65
Q

Clinical features of obstructive sleep apnoea

A 
Obese, middle aged man presents because of snoring or daytime somnolence 
partners often describe apnoeic episodes during sleep 
- loud snoring 
- daytime somnolence 
- poor sleep quality 
- morning headache 
- decreased libido 
- cognitive performance
66
Q

Complications of OSA

A

pulmonary hypertension
type II respiratory failure
independent risk factor for hypertension

67
Q

Investigations for OSA

A

pulse oximetry
polysomnography (O2 sats, airflow at nose and mouth, ECG, EMG chest and abdominal wall movement during sleep) is diagnostic
15+ episodes of apnoea during an hour = severe OSA

68
Q

Management of OSA

A

weight reduction
avoid tobacco and alcohol
CPAP via nasal mask during sleep
Surgery to relieve pharyngeal obstruction - tonsillectomy, uvulopalatopharyngoplasty or tracheostomy

69
Q

What is cor pulmonale

A

right heart failure caused by chronic pulmonary arterial hypertension
- caused by: chronic lung disease, pulmonary vascular disorders, neuromuscular and skeletal diseases

70
Q

Lung disease causes of cor pulmonale

A 
COPD 
Bronchiectasis
Pulmonary Fibrosis 
Severe chronic asthma 
lung resection
71
Q

Pulmonary vascular causes of cor pulmonale

A 
pulmonary emboli 
pulmonary vasculitis 
primary pulmonary hypertension 
ARDS
sickle cell disease 
parasite infection
72
Q

Thoracic cage abnormalities causing cor pulmonale

A

kyphosis
scoliosis
thoracoplasty

73
Q

Neuromuscular causes of cor pulmonale

A

myasthenia gravis
poliomyelitis
motor neurone disease

74
Q

Hypoventilatory causes of cor pulmonale

A

sleep apnoea

enlarged adenoids in children

75
Q

Clinical features of cor pulmonale

A

Symptoms: fatigue, dyspnoea, syncope

Signs: cyanosis, tachycardia, raised JVP w/ prominent a and v waves, RV heave, loud P2, pansystolic murmur (tricuspid regurg) early diastolic Graham Steell murmur, hepatomegaly and oedema

76
Q

Investigations in cor pulmonale

A

FBC - raised Hb and haematocrit (secondary polycythaemia)
ABG- hypoxia± hypercapnia
CXR- enlarged right atrium and ventricle, prominent pulmonary arteries
ECG- P pulmonale, right axis deviation, right ventricular hypertrophy/ strain

77
Q

Management of cor pulmonale

A 
treat underlying causes
treat respiratory failure
treat cardiac failure 
consider venesection if haematocrit >55%
consider heart and lung transplant in young patients
78
Q

Coal worker’s pneumoconiosis

A

dust disease associated with underground mining
result of inhalation of coal dust over 15-20yrs
dust ingested by macrophages which die and release enzymes –> fibrosis

  • asymptomatic but chronic bronchitis is common
  • CXR shows many small round opacities in the upper zone
  • management- avoid exposure, treat chronic bronchitis
79
Q

Progressive massive fibrosis

A

due to progression of coal workers pneumoconiosis
progressive dyspnoea, fibrosis and cor pulmonale
CXR- upper zone fibrotic masses

80
Q

Caplan’s syndrome

A

association between rheumatoid arthritis, pneumoconiosis and pulmonary rheumatoid nodules

81
Q

Silicosis

A

caused by inhalation of silica particles (very fibrogenic)
associated with metal mining, stone quarrying/ sand blasting/ pottery

progressive dyspnoea, increased incidence of TB, CXR- miliary or nodular pattern in upper and mid-zones, egg shell calcification of hilar nodes

82
Q

Asbestosis

A

inhalation of asbestos fibres
progressive dyspnoea, clubbing, fine end crackles
also causes pleural plaques, increased risk of bronchial adenocarcinoma and mesothelioma

83
Q

Malignant mesothelioma

A

tumour of mesothelial cells
usually occurs in the pleura, occasionally peritoneum
clinical features: chest pain, dyspnoea, weight loss, finger clubbing, recurrent pleural effusions

signs of mets- lymphadenoaphty, hepatomegaly, bone pain/tenderness, abdominal pain/obstruction )peritoneal malignant mesothelioma)

84
Q

Idiopathic pulmonary fibrosis

what is it?

A

idiopathic interstitial pneumonia
inflammatory cells infiltrate and pulmonary fibrosis of unknown cause (AKA crytpogenic fibrosing alevolitis)
commonest cause of interstitial lung disease

85
Q

Symptoms of idiopathic pulmonary fibrosis

A 
dry cough 
exertional dyspnoea
malaise
weight loss 
arthralgia
86
Q

Signs of idiopathic pulmonary fibrosis

A

cyanosis
finger clubbing
fine end-inspiratory crepitations

87
Q

Complications of idiopathic pulmonary fibrosis

A

respiratory failure

increased risk of lung cancer

88
Q

Investigations in idiopathic pulmonary fibrosis

A

ABG- low PaO2, high PaCO2 if severe, raised CRP, immunoglobulines
ANA +ve/ rheumatoid factor positive
decreased lung volume, bilateral lower zone reticulonodular shadows, honeycomb lung

89
Q

Management of idiopathic pulmonary fibrosis

A

best supportive care

  • oxygen
  • pulmonary rehabilitation
  • opiates
  • palliative care input
  • *avoid steroids**
90
Q

Interstitial lung disease

clinical features

A 
dyspnoea on exertion 
non-productive paroxysmal cough 
abnormal breath sounds 
abnormal CXR/ high resolution CT
restrictive pulmonary spirometry with reduced DLCO (diffusion capacity of lungs for carbon monoxide)
91
Q

Pathological features of interstitial lung diseases

A

fibrosis and remodelling of the interstitium
chronic inflammation
hyperplasia of type II epithelial cells of type II pneumocytes

92
Q

idiopathic causes of interstitial lung diseases

A

idiopathic pulmonary fibrosis
cryptogenic organising pneumonia
lymphocytic interstitial pneumonia

93
Q

systemic disease causes of interstitial lung disease

A

sarcoidosis
rheumatoid arthritis
SLE, systemic sclerosis, mixed connective tissue diseases, Sjögren’s syndrome
UC, renal tubular acidosis, autoimmune thyroid disease

94
Q

Known causes of interstitial lung disease

A 
occupational/ environmental 
drugs- nitrofurantoin, bleomycin, amiodarone, sulfasalazine, busulfan
hypersensitivity reactions
infections  - TB, funghi, viral
GORD
95
Q

Extrinsic allergic alveolitis

A

inhalation of allergens (fungal spores or avian proteins)
provokes hypersensitivity reaction
acute phase- alveoli are infiltrated with acute inflammatory cells

chronic - granuloma formation and obliterative bronchiolitis occur

96
Q

Causes of extrinsic allergic alveolitis

A

bird-fancier’s lung and pigeon’s fancier lung
farmer’s and mushroom worker’s lung
malt worker’s lungn
Bagassosis or sugar worker’s lung

97
Q

Clinical features of extrinsic allergic alveolitis

A

4-6 hours post exposure - fevers, rigors, myalgia, dry cough, dyspnoea, crackles (no wheeze)

Chronic - increasing dyspnoea, weight loss, exertional dyspnoea, type I respiratory failure, cor pulmonale

98
Q

Tests for extrinsic allergic alveolitis

Acute

A

FBC - neutrophilia, raised ESR
ABG- positive serum precipitins
CXR- upper zone mottling consolidation, hilar lymphadenopathy
Lung function tests - reversible restrictive defect, reduced gas transfer during acute attacks

99
Q

Tests for extrinsic allergic alveolitis

Chronic

A

Blood tests- positive serum precipitins
CXR- upper zone fibrosis, honey comb lung
Lung function tests- persistent changes, BAL shows raised lymphocytes and mast cells

100
Q

Management of extrinsic allergic alveolitis

A

remove allergen and give O2. Oral prednisolone 40mg/24hrs then reducing dose

avoid exposure and long term steroids

101
Q

What is sarcoidosis?

A

systemic granulomatous disorder of unknown causes
usually affects adults aged 20-40, more common in women
African-Caribeans more frequently and severely esp. extra-thoracic disease

associated with HLA-DRB1 and DQB1

102
Q

Clinical features of sarcoidosis

pulmonary

A

erythema nodosum ± polyarthralgia
CXR with bilateral hilar lymphadenopathy ± pulmonary infiltrate or fibrosis

dry cough, progressive dyspnoea, decreased exercise tolerance, chest pain

103
Q

Non-pulmonary features of sarcoidosis

A 
lymphadenopathy
hepatomegaly 
splenomegaly
uveitis
conjunctivitis, 
keratoconjunctivitis sicca
glaucoma
terminal phalageal bone cyst 
enlargement of lacrimal glands 
Bell's palsy 
meningitis
brain stem and spinal syndromes 
SOL 
erythema nodusum
lupus pernio
subcutaneous nodules
cardiomyopathy
arrhythmias
hypercalaemia/hypercalciuria
renal stones 
pituitary dysfunction
104
Q

Management of Sarcoidosis

A

acute- bed rest and NSAIDs
bilateral hilar lymphadenopathy -alone- no treatment

Indications for corticosteroids- parenchymal lung disease, uveitis, hypercalcaemia, neurological or cardiac involvement - Prednisolone 40mg/24 4-6/52 and gradually reduce over 1yr

105
Q

Causes of bilateral hilar lymphadenopathy

A

Sarcoidosis
infection - TB, mycoplasma
Malignancy e.g. lymphoma, carcinoma, mediastinal tumours
organic dust disease e.g. silicosis or berylliosis
Extrinsic allergic alveolitis
Histocytosis X

106
Q

Pleural effusion

definition

A

fluid in the pleural space
Transudates –> <25g/L of protein
Exudates –> >35g/L of protein

107
Q

Causes of transudates

A

increased venous pressure (cardiac failure, constrictive pericarditis, fluid overload)
hypoproteinaemia (cirrhosis, nephrotic syndrome, malabsorption)

108
Q

Causes of exudates

A

increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy

pneumonia, TB, pulmonary infarction, rheumatoid arthritis, SLE, bronchogenic carcinoma, malignant metastases, lymphoma, mesothelioma, lymphangitis carcionmatosis

109
Q

Symptoms of pleural effusions

A

asymptomatic
dyspnoea
pleuritic chest pain

110
Q

Signs of pleural effusions

A

decreased expansion
stony dull percussion note
diminished breath sounds
may be bronchial breathing or tracheal deviation

111
Q

Management of pleural effusions

A

drainage
pleurodesis for recurrent effusions (tetracycline, bleomycin or talc)
intra-pleural streptokinase - no benefit
surgery- persistent collections and increasing pleural thickness on US requires surgery

112
Q

Causes of pneumothorax

A

often spontaneous in young thin men due to rupture of sub-pleural bulla

other causes - asthma, COPD, TB, pneumonia, lung abscess, carcinoma, CF, lung fibrosis, sarcoidosis, connective tissue disorders, trauma, iatrogenic

113
Q

Symptoms of pneumothorax

A

asymptomatic
sudden onset dyspnoea ± pleuritic chest pain
sudden deterioration (asthma/COPD)
hypoxia/ increased ventilation pressures

114
Q

Signs of pneumothorax

A

reduced expansion
hyper-resonance to percussion
diminished breath sounds
tension pneumothorax- tracheal deviation from the addected side

115
Q

Management of pneumothorax

A

place a chest drain

116
Q

Causes of PE

A 
venous thrombosis in pelvis or legs
rare causes: 
right ventricular thrombus (post MI)
septic emboli (right sided endocarditis)
fat, air or amniotic fluid embolism 
neoplastic cells 
parasites
117
Q

Risk factors of PE

A 
recent surgery esp. abdo/pelvic/hip/knee 
thrombophilia
leg fracture 
prolonged bed rest/reduced mobility 
malignancy
pregnancy/post partum; Pill/HRT
Previous PE
118
Q

Clinical features of PE

A 
acute breathlessness
pleuritic chest pain 
haemoptysis
dizziness
syncope
pyrexia, cyanosis, tachypnoea, tachycardia, hypotension, raised JVP, pleural rub, pleural effusion
119
Q

Tests for PE

A

FBC, U&E, baseline clotting, D-dimers
ABG- low PaO2 and low PaCO2
CXR- normal, oligaemia, dilated pulmonary artery, linear atelectasis, small pleural effusion
ECG- tachycardia, RBBB, R ventricular strain

120
Q

Treatment of PE

A

Anticoagulate with LMWH
warfarin minimum of 3 months
thrombolysis for massive PE (alteplase)
Vena caval filter

121
Q

Prevention of PE

A

give heparin to all immobile patients
prescribe compression stockings
encourage early mobilisation
stop HRT & the Pill pre-op

122
Q

Causes of type I respiratory failure

hypoxia with normal PaCO2

A

ventilation/perfusion (V/Q) mismatch

  • pneumonia
  • pulmonary oedema
  • PE
  • asthma
  • emphysema
  • pulmonary fibrosis
  • ARDS
123
Q

Causes of type II respiratory failure

hypoxia with hypercapnia

caused by alveolar hypoventilation ± V/Q mismatch

A

pulmonary disease- asthma, COPD, pneumonia, end-stage pulmonary fibrosis, obstructive sleep apnoea

Reduced respiratory drive- sedative drugs, CNS tumour or trauma

Neuromuscular disease- cervical cord lesion, diaphragmatic paralysis, poliomyelitis, myasthenia gravis, Guilllan-Barré syndrome

Thoracic wall disease - flail chest, kyphoscoliosis

124
Q

Clinical features of respiratory failure

A

hypoxia - dyspnoea, restlessness, agitation, confusion, central cyanosis (long standing - polycytheamia, pulmonary htn, cor pulmonale)

Hypercapnia - headache, peripheral vasodilatation, tachycardia, bounding pulse, tremor/flap, papilloedema, confusion, drowsiness, coma

125
Q

Investigating resp failure

A

bloods- FBC, U&E, CRP, ABG
CXR
microbiology- sputum and blood cultures
spirometry

126
Q

Management of type I resp failure

A

treat underlying cause
give oxygen
assisted ventilation

127
Q

Management of type II resp failure

A

may have CO2 insensitivity- SpO2 88-94%

  • treat underlying cause
  • controlled oxygen therapy - repeat ABG after 20mins
  • if this fails consider intubation and ventilation
128
Q

Causes of ARDS (acute respiratory distress syndrome)

A

pulmonary - pneumonia, gastric aspiration, inhalation, injury, vasculitis, confusion

other- confusion, haemmorrhage, multiple transfusions, pancreatitis, acute liver failure, trauma, head injury, malaria, fat embolism, obstetric events, drugs/toxins

129
Q

clinical features of ARDS

A 
cyanosis 
tachypnoea
tachycardia
peripheral vasodilatation
bilateral fine inspiratory crackles
130
Q

Investigations of ARDS

A

FBC, U&E, amylase, clotting, CRP, blood cultures, ABG

CXR shows bilateral pulmonary infiltrates

131
Q

Diagnostic criteria of ARDS

A
  1. Acute Onset
  2. CXR- bilateral infiltrates
  3. pulmonary capillary wedge pressure <19mmHg/ lack of clinical congestive heart failure
  4. refractory hypoxaemia
132
Q

Management of ARDS

A
  1. Admit to IT, supportive therapy, treat underlying causes
    - resp support - CPAP (risk for pneumothorax)
    - circulatory support - arterial line
    - sepsis
    - nutritional support
133
Q

Symptoms of COPD

A

cough
spututm
dyspnoea
wheeze

134
Q

Signs of COPD

A 
tachypnoea
use of accessory muscles of respiration 
hyperinflation 
decreased cricosternal distance 
decreased expansion
resonant or hyperresonant percussion note 
quiet breath sounds
wheeze
cyanosis 
cor pulmonale
135
Q

Complications of COPD

A 
Acute exacerbations ± infection 
polycythaemia 
respiratory failure
cor pulmonale (oedema, raised JVP)
pneumothorax (ruptured bullae)
lung carcinoma
136
Q

tests in COPD

A

FBC- PCV raised,
CXR- hyperinflation, flat hemi-diaphragms, large central pulmonary vessels, decreased peripheral vascular markings, bullae
ECG- right atrial and ventricular hypertrophy
ABG- low PaO2 ± hypercapnia
Lung function tests- obstructive + air trapping FEV1 <80%

137
Q

Treatment of COPD

Chronic stable - general

A 
stop smoking 
encourage exercise
treat poor nutrition or obesity 
influenza and pneumococcal  vaccines
pulmonary rehabilitation 
palliative care 
Non-invasive positive presssure ventilation 
PRN short-acting antimuscarinic (ipratropium) or B2 agonist
138
Q

Treatment of COPD

Mild/moderate disease

A

inhaled long-acting antimuscarinic (tiotropium) or B2 agonist (salmeterol)

139
Q

Treatment of severe COPD

A

combination of long acting B2 agonist (salmeterol)+ cortiocosteroids
e.g. Symbicort (budenoside + formoterol) or tiotropium

140
Q

Characteristics of asthma

A

recurrent episodes of dyspnoea, cough and wheeze caused by reversible airway obstruction

  • bronchial muscle contraction
  • mucosal swelling/ inflammation caused by mast cell and basophils
  • increased mucus production
141
Q

Symptoms of asthma

A

intermittent dyspnoea
wheeze
cough (often nocturnal)
sputum

142
Q

What to ask about in asthma?

A 
precipitants- cold air, exercise, allergens, infection, smoking/ passive smoking 
diurnal variation- marked moring dipping
exercise
disturbed sleep 
acid reflux 
other atopic disease 
the home 
job
days off/ week due to chest
143
Q

Signs of asthma

A 
tachypnoea
audible wheeze
hyperinflated chest
hyperresonant to percussion 
reduced air entry
widespread polyphonic wheeze
144
Q

Signs of severe asthma attach

A

inability to complete sentences
pulse>110 bmp
resp rate >25
PEF 33-50% of predicted

145
Q

signs of life threatening asthma attack

A 
silent chest
confusion 
exhaustion 
cyanosis
bradycardia
REF <33% predicted
146
Q

Differential diagnosis of asthma

A 
pulmonary oedema- cardiac asthma 
COP
large airway obstruction- foreign body, tumour
SVC obstruction 
pneumothorax
PE 
bronchiectasis
obliterative bronchiolitis
147
Q

Diseases associated with asthma

A

Acid-reflux
polyarteritis nodosa
Churg-Strauss

3B General Care (8 decks)

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