Respiratory Flashcards
According to NICE guidelines, what recommendations should be given to those with COPD?
- Smoking cessation advice (NRT, varnicline, bupropion)
- Annual influenza vaccination
- One off pneumococcal vaccination
- Pulmonary rehab to those with MRC grade 3 and above
What is the 1st line treatment for COPD?
Short acting beta2 agonist (eg. salbutamol) or short acting muscarinic antagonist (eg. ipratropium or oxatroprium bromide)
If a pt remains symptomatic with short acting bronchodilators, what is the next step in management?
First, determine whether the patient has ‘asthmatic features/features suggesting steroid responsiveness’ - eg. previous dx asthma/atopy, eosinophilia, substantial (>400ml) variation in FEV1 over time, substantial diurnal variation in peak expiratory flow (>20%)
NO asthmatic features:
Add long-acting beta2 agonist (eg. tiotropium) and long actinic muscarinic antagonist (eg. -rol)
If taking SMA, discontinue and switch to SABA
Asthmatic features:
LABA + ICS
NICE recommend the use of combined inhalers where possible
If a pt with asthmatic features of COPD remains breathless on SABA + LABA + ICS, what is the next step in treatment?
Triple therapy ie. LAMA + LABA + ICS
(if taking SAMA, discontinue and switch to SABA)
If a pt remains symptomatic after trials of short and long acting bronchodilators, or cannot use inhaled therapy, what treatment is recommended in COPD?
Theophylline
In which circumstances should a reduced dose of theophylline be prescribed?
If a macrolide or fluoroquinolone is co-prescribed
What oral prophylactic antibiotic therapy is indicated in select COPD patients? What are the prerequisites for treatment?
Azithromycin
Its must not smoke, have optimised standard treatments, and continue to have exacerbations
Must have CT thorax to exclude bronchiectasis and sputum culture to exclude atypical infections and TB
Must have LDT and ECG to exclude QT prolongation (azithromycin can prolong QT)
When should mucolytics be prescribed in COPD?
Patient with a chronic productive cough - only continue if symptoms improve
When should oral phosphodiesterase-4 (PDE-4) inhibitors be used in COPD?
Patients must have:
- Severe COPD (FEB1 less than 50% of predicted normal after bronchodilator therapy)
- History of frequent COPD exacerbations (2 or more in last 12 months despite triple therapy)
What is an example of a PDE-4 inhibitor?
Roflumilast
What is cor pulmonale and how is it treated?
Cor pulmonale is abnormal right sided hypertrophy due to lung disease. Features include peripheral oedema, raised JVP, systolic parasternal heave and loud P2
Treatments include:
- Loop diuretic for oedema (eg furosemide, bumetanide)
- LTOT
Which treatments are not recommended in cor pulmonale that may be used in CCF?
ACEis, CCBs, alpha blockers
Which factors improve survival in patients with stable COPD?
Smoking cessation (most IMPORTANT)
LTOT (if fit criteria)
Lung volumer reduction surgery
What is CURB65?
Confusion (AMT <= 8)
Urea (>=7)
RR (>= 30)
BP (systolic <=90, diastolic <=60)
Age (>=65)
0/1 - low risk, treat at home
2 - intermediate risk, consider hospital
3 or more - high risk, urgent hospital admission
What are NICEs recommendation on abx treatment for pneumonia, when considering CRP?
CRP <20 - no routine abx
CRP 20-100 - consider or offer delayed abx
CRP >100 - abx
What investigations do NICE recommend for pneumonia?
CXR and CRP
Intermiediate/high risk patients should have blood and sputum cultures, pneumococal and legionella urinary antigens
What is 1st line therapy for low severity CAP?
Amoxicillin - 5d course
Penicillin allergy - macrolide (eg. clari/erythromycin) or tetracycline (eg. doxy)
What is 1st line therapy for moderate or high severity CAP?
7-10d course dual antibiotic therapy with amoxicillin + macrolide
Consider co-amoxiclav/ceftriazxone/piptaz + clarithromycin in high severity
NICE would recommend that patients are not routinely discharged if they have had 2 or more of which findings in the last 24h?
- Temperature higher than 37.5°C
- Respiratory rate 24 breaths per minute or more
- Heart rate over 100 beats per minute
- Systolic blood pressure 90 mmHg or less
oxygen saturation under 90% on room air - Abnormal mental status
- Inability to eat without assistance.
How long should the following symptoms resolve after pneumonia?
a) fever
b) chest pain/sputum reduced
c) cough and SOB reduced
d) most symptoms except fatigue
e) back to normal
a) 1 week
b) 4 weeks
c) 6 weeks
d) 3 months
e) 6 months
What investigation should be done for all cases of pneumonia 6 weeks after clinical resolution?
CXR - if abnormal needs in detail imaging
What are the most common causes of an anterior mediastinal mass?
4 Ts - teratoma, terrible lymphadenopathy, thymic mass (thymoma/thymoid cancer) and thyroid mass
Why is a CT chest done in myasthenia graves?
To look for a thymoma - removal of thymoma may improve condition and helps prevent malignant transformation
What is the mediastinum?
The region between the pulmonary cavities, extending from the thoracic inlet superiorly to the diaphragm inferiorly.
Composed of 4 regions - superior/middle/posterior/anterior
The mediastinum contains the heart, great vessels, teaches and many essential nerves
What is the role of the thymus gland and where is it located?
Makes white blood cells ( T lymphocytes)
Located in the mediastinum
What are the most common infective causes of COPD exacerbations ?
Bacteria:
Haemophilus influenzae
Streptococcus pneumoniae
Moraxella catarrhalis
Virus (30%):
Rhinovirus
When should abx be given in an exacerbation of COPD?
Purulent sputum
Clinical features of pneumonia
How is an ECOPD managed?
- Increase frequency of bronchodilator +/- give via a nebuliser
- 5d course prednisolone 30mg
- Abx only if purulent sputum/clinical features of pneumonia (amoxicillin/clarithromycin/doxycycline)
What are the criteria for admission with an ECOPD?
- Severe SOB
- Acute confusion
- Cyanosis
- Sats<90%
- Social reasons
- Significant comorbidity (eg. cardiac disease or insulin dependent diabetes)
Prior to ABG analysis, what initial oxygen treatment should you give to patients with a COPD exacerbation ?
28% venturi mask at 4L/min - aim sats 88-92% (adjust to 94-98% if pC02 is normal)
How is a severe exacerbation of COPD managed in hospital?
- Oxygen therapy
- Nebulised bronchodilator (salbutamol, ipratropium)
- Steroid therapy (oral pred or IV hydrocortisone)
- IV theophylline (if not responding to bronchodilators)
May need NIV if:
- Resp acidosis (not necessarily T2RF)
- T2RF
Start biPaP with initial EPAP 4-5cm H20 and initial IPAP 10-25cm H20
How does CPAP work and when is it used?
Creates positive pressure by increasing gas exchange by recruitment of alveoli (uses PEEP and high flow)
Used in T1RF in:
- Cardiogenic pulmonary oedema
- Congestive heart failure
- Pneumonia
- Sleep apnoea
NB CPAP is not NIV!!!!!!
How does NIV work and when is it used?
Inspiratory push behind breath + PEEP to increase tidal volume and decrease C02
Used in T2RF:
- COPD
- Pneumonia
- Post extubation and to prevent intubation
- Cardiogenic pulmonary oedema
How is asthma diagnosed?
CLINICAL diagnosis - more than one of wheeze, SOB, chest tightness, cough + variable airflow obstruction (worse at night and early morning)
How do you manage a new diagnosis of high probability asthma?
Commence SABA ?check
Corroborate with lung function tests
If poor response to treatment - check inhaler technique and adherence, arrange further tests and consider alternative diagnoses
How do you manage a case of intermediate probability asthma?
Spirometry with bronchodilator reversibility +/- monitored initiation of treatment
+/- challenge tests, measure FeNO (eosinophils)
If unable to perform spirometry, consider watchful waiting if asymptomatic, or start trial
Describe some primary prevention initiatives to reduce asthma occurrence
Breast feeding
Weight loss in obese children
Smoking cessation (parents)
Allergen avoidance is NOT recommended
Describe some secondary prevention initiatives to prevent asthma xacerbations
Weight loss in obese children
Smoking cessation
Breathing exercise programmes
Dust mite reduction is NOT recommended
How do you define complete control of asthma?
- No daytime symptoms
- No nighttime awakening
- No need for rescue medication
- No asthma attacks
- No limitations of activity
- Normal lung function (>80% predicted/best)
- Minimal side effects from medications
What is the 1st step in pharmacological asthma treatment?
Prescribe an inhaled SABA as short term deliver therapy
What is the 2nd step in pharmacological asthma treatment?
SABA + ICS (give twice daily except for ciclesonide which is given OD)
NB - Smokers may need higher doses
What is the 3rd step in pharmacological asthma treatment?
SABA + ICS + LRTA (give LRTA before increasing ICS)
Note LRTA is an oral therapy taken at night so if you think unlikely to be adherent give LABA instead
What is the 4th step in pharmacological asthma treatment?
Increase dose of ICS or consider adding LABA
What is the 5th step in pharmacological asthma treatment?
Refer to specialist care where they may start theophyllines/sodium cromoglicate
How often should asthma patients be reviewed?
3 monthly to consider reducing treatment
ICS - reduce by 25-50% at a time
What device is preferred for delivery of medication in asthma?
If in doubt, pMDI +/- spacer in children
Face mask required until child can breathe reproducibly using spacer
What are the features of a moderate acute asthma attack?
Increasing symptoms
PEF>50-75% best or predicted
No features of acute severe asthma
What are the features of an acute severe asthma attack?
PEF 33-50% best or predicted
RR >= 25 (>40 in 1-5y, >30 in over 5 yrs)
HR >= 110 (>140 in 1-5y, >125 in over 5 yrs)
Inability to complete sentences
What are the features of a life threatening asthma attack?
PEF <33%
sP02 <92%
pa02 <8 kpa
Altered consciousness
Exhaustion
Arrhythmia
Hypotension
Cyanosis
Silent chest
Poor respiratory effort
How is an acute asthma attack managed in adults?
- Oxygen
- Beta agonist bronchodilators (high dose >nebs/IV)
- Steroid therapy (prednisolone 40-50mg daily until recovered)
- Ipratropium bromide nebs (if severe/life threatening or poor response to beta agonists)
Consider single dose IV Mg (1.2-2g over 20 minutes) if severe or poor response to above therapies
Consider IV aminophylline/salbutamol if still refractory (caution and may require ICU admission for cardiac monitoring)
What is the follow up for adults after an acute severe asthma attack?
Inform primary care physician within 24h
Respiratory specialist for at least 1 year
How is an acute asthma attack managed in children OOH?
Increase SABA by giving one puff every 30-60s up to a maximum of 10
If not controlled - seek urgent medication attention
If severe symptoms, given additional doses of SABA whilst awaiting ambulance
Nebulised salbutamol to be given in ambulance if severe
How is an acute asthma attack managed in children?
- Beta agonist treatment + oral steroids is 1st line
- Give nebuliser ipratropium bromide if refractory
- Consider adding Mg to each nebuliser if sp02 <92%
- Consider IV salbutamol if treatment refractory
- Consider aminophylline if severe/lifre threatening
- Consider IV Mg if treatment refractory
Oral steroids - 10mg pred if child under 2 years old, 20mg pred if child 2-5 years old, 30-40mg pred if child >5 years old
If on maintenance oral steroids can have a max of 60mg OD
Treatment for 3 days is usually sufficient
What is the follow up for an acute asthma attack in children? (PEF/FEB1 must be over 75% and Sp02 must be over 94%)
Discharge home with 3-4hrly inhaled bronchodilators
Primary care f/u within 2 days
Paediatric asthma clinic within 1 month
Paediatric respiratory specialist only if life threatening features
How is asthma managed in pregnancy?
No changes to any medication including use of steroids in severe asthma (benefits outweig risks and this applies to breastfeeding also )
Continuous fetal monitoring recommended for pregnant women admitted with acute severe asthma
How is asthma managed during labour?
- If anaesthesia is required, regional blockade is preferable to GA due to the risk of bronchospasm
- Use prostaglandin F2a with extreme caution due to risk of bronchoconstriction
- Women receiving prednisolone >75mg OD for >2 weeks prior to delivery should receive parenteral hydrocortisone 100mg 6-8hrly during labour
What is acute bronchitis and how is acute bronchitis treated?
A type of chest infection due to inflammation of the trachea and major bronchi. Usually viral and self limiting and resolves within 3 weeks.
Only give abx if high risk of complications or systemically unwell
Oral doxycycline
What lung disease can asbestos cause?
- Pleural plaques
- no malignant change
- latent period 20-40 years - Pleural thickening
- Asbestosis
- causes dyspnoea/clubbing/end insp crackles
- restrictive pattern on LFTs
- treat conservatively
- latent period 15-30 years - Mesothelioma
- progressive SOB/chest pain/pleural effusions
- palliative chemotherapy
- prognosis 8-14 months - Lung cancer
- synergistic effect with cigarette smoke in terms of increased risk
What are the most common form of lung cancer and its normal location?
- Adenocarcinoma
Location: peripheral - Squamous cell carcinoma
Usually related to smoking
Associated with hypercalcemia (paraneoplastic)
Location: central
How are lung cancers diagnosed/biopsied?
Central tumour - bronchoscopy
Peripheral tumours - CT/US guided biopsy
If undiagnosed despite above - thoracoscopy
Evaluate LN status - mediastinoscopy
What are the features of small cell lung cancer?
- Often associated with paraneoplastic syndromes (Cushings, SIADH, Lambert-Eaton myasthenic syndrome)
What is IPF and how do you diagnose IPF?
A chronic lung condition characterised by progressive fibrosis of the interstitium of the lungs, when no underlying cause has been identified
Symptoms include progressive exertional dyspnoea, bibasal find end inspiratory crepitations, dry cough, clubbing
Restrictive ie. FEV1 normal/decreased, FVC decreased, FEF1/FVC increased
Impaired gas exchange ie. reduced TLCO
Bilateral interstitial shadowing (ground glass opacities) on CXR/HRCT
ANA positive in 30%
How is IPF managed?
Pulmonary rehab
Medicines generally not effective - can trial pirfenidone (antifibrotic agent) in selected patients
LTOT
Lung transplant
Prognosis 3-4 years
Which conditions cause restrictive lung picture on spirometry?
Pulmonary fibrosis
Asbestosis
Sarcoidosis
ARDS
Kyphoscloiosis eg. ank spon
Neuromuscular disorders
Severe obesity
Which conditions cause an obstructive picture on spirometry?
Asthma
COPD
Bronchiectasis
Bronchiolitis obliterans
What are the typical features of mesothelioma?
Presents as dyspnoea, weight loss, chest wall pain and clubbing
30% present as painless pleural effusion
Metastasize to contralateral lung and peritoneum
Right lung more often affected than left
How is mesothelioma diagnosed ?
Pleural CT +/- image guided pleural biopsy
Cytology/MC&S of pleural effusion
How is mesothelioma managed?
Symptomatic
Industrial compensation
Chemotherapy +/- surgery
Poor prognosis, median survival 12 months
What are the spirometry results for the different stages of COPD?
Stage 1 (mild) - FEV1>= 80%
Stage 2 (moderate) - FEV1 50-79%
Stage 3 (severe) - FEV1 30-49%
Stage 4 (very severe) - FEV1 <30%
How is primary pneumothorax managed?
Primary (no underlying lung disease)
- If rim of air <2cm and not SOB, consider discharge
- otherwise, attempt aspiration
- if failed, insert chest drain
How is secondary pneumothorax managed?
- if pt >50yo and rim of air >2cm and/or SOB, insert chest drain
- if 1-2cm, attempt aspiration (and drain if fails). admit for 24 h
- if <1cm, give oxygen and admit for monitoring for 24h
How is iatrogenic pneumothorax managed?
Usually resolve with observations
May need aspiration
If ventilated/COPD need chest drain
How is persistent/recurrent pneumothorax managed?
If persistent air leak or insufficient lung reexpansion despite chest drain insertion, or recurrent pneumothoraces > consider VATS (video assisted thoracoscopic surgery) to allow for pleurodesis +/- bullectomy
What discharge advice should you give post pneumothorax?
- Avoid smoking
- No flying until 1 week post check CXR (provided complete resolution)
- No scuba diving for LIFE
What is Light’s criteria?
States that a pleural effusion is an exudate if:
- LDH greater than 2/3 upper limit of serum LDH
- Pleural fluid LDH/serum LDH >0.6
- Pleural fluid protein/serum protein >0.5
What causes exudative pleural effusion?
Exudative pleural effusions are caused by changes to the local factors that influence the formation and absorption of pleural fluid.
Malignancy
Infection
Trauma
Pulmonary infarction
Pulmonary embolism
Usually have WCC>50000, protein >30, high LDH
What causes transudative pleural effusion?
Transudative pleural effusions are defined as effusions that are caused by factors that alter hydrostatic pressure, pleural permeability, and oncotic pressure.
Heart failure
Liver failure
Nephrotic syndrome
Severe hypoalbuminaemia
Usually have WBC <1000, protein <30, low LDH
What does low glucose suggest in a pleural effusion?
Rheumatoid arthritis
TB
What does raised amylase suggest in a pleural effusion? What about heavy blood staining?
a) Pancreatitis
Oesophageal perforation
b) Mesothelioma
TB
PE
How are recurrent pleural effusions managed?
Recurrent aspiration
Pleurodesis
Indwelling pleural catheter
Drug management to alleviate symptoms
When should a chest drain be inserted after pleural tap?
If fluid is purulent or turbid, to allow drainage
If fluid is clear but pH<7.2 if suspected pleural infection
What are the symptoms of OSA and its predisposing factors?
Symptoms - excessive snoring, periods of apnoea, daytime somnolence, compensated respiratory acidosis, hypertension
Risk factors - obesity, macroglossia, acromegaly, hypothyroidism, amyloidosis, large tonsils, Marfan’s
How is OSA assessed?
- Epworth sleepiness scale
- Multiple sleep latency test (time it takes to fall asleep in dark room using EEG)
- Polysomnography
How is OSA managed?
- Weight loss
- CPAP first line for moderate/severe
- Mandibular advancement (only if CPAP not tolerated or only mild symptoms)
- Inform DVLA
Tell me about klebsiella pneumonia
Gram negative rod
More common in diabetes and ETOH
Causes cavitation in upper lobes (upper zone crackles)
Tell me about legionella pneumophilia
Causes Legionnaire’s disease
Atypical pneumonia that spreads via contained water supply
Causes fever, cough, myalgia and bilateral chest symptoms
Extra-pulmonary symptoms (hyponatremia, hepatitis)
Tell me about mycoplasma pneumoniae
Causes atypical pneumonia
Causes coryza and dry cough
Extra-pulmonary symptoms (haemolytic anaemia, erythema multiforme)
Tell me about staphylococcus aureus
Most common cause of pneumonia after influenza virus
Preceding corzyal symptom
Tell me about streptococcus pneumoniae
Most common causes of CAP
Fever, productive cough, SOB
What are the NICE recommendations for management of smoking cessation?
Offer NRT, varenicicline or buproprion
Start with a target stop date. Prescribe management to last only until 2 weeks after target stop date for NRT, and 3-4 weeks for varenicline and buproprion
Only offer continued prescription to people who have demonstrated that their quit attempt is continuing
If unsuccessful do not offer a repeat prescription within 6 months
Do not offer in combination
How is NRT usually prescribed?
Combination of nicotine patch and other form (gum/inhalator/lozenge/nasal spray)
How does varenicline work? What are the side effects, cautions and contra-indications?
Nicotinic receptor partial agonist
Usually give for 12 weeks
SE: headache, insomnia, abnormal dreams
Cautions: depression, self-harm
CI: pregnancy, breast-feeding
How does bupropion work? What are the side effects, cautions and contra-indications?
Norepinephrine and dopamine reuptake inhibitor and nicotinic antagonist
Cautions: risk of seizures
CIs: epilepsy, pregnancy and breast feeding, eating disorder
What are the NICE recommendations for pregnancy and smoking?
All pregnant women should be tested for smoking using carbon monoxide sectors
If reading >7ppm, refer to NHS Stop Smoking Services
1st line - CBT, self-help
2nd line - NRT, remove patches before bed
Which conditions cause CXR findings of bilateral hilar lymphadenopathy?
Sarcoidosis
Tuberculosis
Lymphoma/malignancy
Pneumoconiosis
Fungal (histoplasmosis, coccidiodomycosis)
What are pneumoconioses?
A group of interstitial lung diseases caused by the lung’s reaction to inhaling certain exposure. This may be simple (nodules on CXR) or complicated AKA progressive mass fibrosis
Examples include:
Asbestosis
Coal workers
Brown lung (cotton fibres)
Silicosis (miners/potters)
Berylliosis
How are the pneumoconioses managed?
Investigate with CXR, spirometry, BeLPT in first instance
Consider lavage, HRCT, oxygen sats, ABG
Oxygen therapy
Pulmonary rehab
Steroids (for berylliosis)
Occupational compensation
What is sarcoidosis?
A multi systemic inflammatory disorder of unknown ethology causing non-caveating epithelioid granulomas in the lung. Patients present with SOB and persistent dry cough
Diagnosis - clinicoradiologic findings + histological analysis
Can be acute - ankle swelling, erythema nodosum, young white adults, swinging fevers, polyarthralgia, lupus pernio
Can be chronic - lung infiltration, resistance to conventional treatment, afro-caribbean, multi system
How is sarcoidosis treated?
Usually no treatment is needed. Spontaenous remission occurs in:
- 90% of patients with bilateral hilar lymphadenopathy (stage 1 disease)
- 50% of patients with BHL and pulmonary shadowing (stage 2 disease)
In patients with stage 2/3 disease who have moderate to severe progressive symptoms or changed on CXR:
- 1st line; Oral steroids, 6-24month taper +bisphosphonate
- 2nd line; Immunosuppressants
Aspirin can be used for erythema nodosum
What is tuberculosis ?
A curable infection causing formation of tubercles and caseous necrosis secondary to infection with mycobacterium tuberculosis
What is latent TB and what is the likelihood of catching it?
When the TB bacteria lie dormant (20% of cases). This is not infectious but if later immunosuppression latent TB can spread to the lung or elsewhere to cause active infection
Which symptoms should make you suspect pulmonary TB?
Cough for >3 weeks particularly if accompanied by haemoptysis, SOB, weight loss, fever/sweats, lymphadenopathy
Urgent ix with CXR and sputum smear + Ziehl-Nielsen stain to look for acid fast bacilli
3 respiratory samples are preferred (1 early morning), may need lavage
What is the NICE guidance on latent TB?
Offer mantoux testing to those aged 18-65 in close contact with patients with TB
If inconclusive, refer to TB specialist
If positive, consider interferon-gamma release assay
If positive, assess for active TB and treat accordingly
What are the radiological findings of TB?
HIlar lymphadenopathy
How is latent TB treated?
Young, low risk - 3 months isoniazid (with pyridoxine) and rifampicin
Elderly, more complicated patients - 6 months isoniazid (with pyridoxine)
How is active TB treated?
1st line - 6 months of isoniazid (with pyridoxine) and rifampicin. Pyraxinamide and ethambutol given in first 2 months.
May need to be longer treatment if CNS TB, MDR TB
What are the side effects of isoniazid?
Drug induced lupus
Neuropathy
What are the side effects of rifampicin?
Red discolouration of urine
What are the side effects of pyrazinamide?
GI symptoms
Hyperuraemia
Gout
What are the side effects of ethambutol?
Optic neuritis
What is A1AT deficiency?
Alpha-1 antitrypsin deficiency is a common inherited condition causing by a lack of protease inhibitor normally produced by the liver. The role of A1AT is to protect cells from enzymes such as neutrophil elastase. Due to its deficiency, elastin is not broken down in the lungs.
Autosomal recessive, serpina 1 gene located on chromosome 14, most common is PiZ mutation
What signs and symptoms does A1AT deficiency cause?
Emphsema in patients who are young and non-smoker
Lungs: panacinar emphysema, most marked in lower lobes
Liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
How is A1AT deficiency managed?
- No smoking
- Bronchodilators/physiotherapy
- Intravenous A1AT protein concentrates
- Lung volume reduction surgery, lung transplant
How does A1AT present in childhood?
Jaundice, acute liver failure
How is A1AT diagnosed?
Blood test - A1At
CXR/HRT and pulmonary function tests - obstructive picture
Liver USS + biopsy - periodic acid schiff, diastase positive
What CXR findings would you see with silicosis?
Bilateral upper zone fibrosies (upper due to inhalation of toxic substance, as upper lobes have a higher VQ ratio)
Egg shell calcification of hilar nodes
(miners, potters)
What CXR findings would you see with asbestosis?
Pleural plaques
Lower lobe fibrosis
(firefighters, dockyard workers, construction workers)
What are the symptoms of a lung abscess?
Night sweats, weight loss, severe, foul sputum
Tends to be more subacute than pneumonia
CXR shows a fluid filled space within an area of consolidation
An air fluid level is typically seen
What causes a lung abscess?
Aspiration pneumonia
Poor dental hygiene
Haematogenous spread eg. IE
Extension from empyema
Bronchial obstruction due to tumour
Polymyocrobial
How is a lung abscess managed?
Send sputum and blood cultures
IV antibiotics - clindamycin 4-6 weeks
If not resolving, percutaneous drainage and consider surgical resection
What is bronchiectasis? How is it managed?
Permanent dilatation of the airways secondary to chronic infection or inflammation (often H influenza)
Management:
1. Assess for treatable causes (eg. immune deficiency)
2. Physical training - inspiratory muscle training
3. Postural drainage
4. Abx for exacerbations +/- prophylaxis
5. Bronchodilators
6. Immunisations
7. Surgery in selected cases
What are the risk factors for lung cancer?
Main risk factor - smoking incl passive smoking
Others:
Asbestos (synergistic with smoking)
Arsenic
Radon
Nickel
Chromate
Aromatic hydrocarbon
Cryptogenic fibrosing alveoli’s
What is the main therapeutic benefit of ICS in COPD?
Reduced frequency of exacerbations
What spirometry would you expect in obstructive lung disease?
FEV1 significantly reduced
FVC reduced or nomral
FEV1/FVC reduced
What spirometry would you expect in restrictive lung disease?
FEV1 reduced
FVC significantly reduced
FEV1/FVC normal or increased
Why do patients with sarcoidosis get hypercalcemia?
Macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)
What is Lofgren’s syndrome?
An acute form of sarcoidosis characterised by bilateral hilar lymphadenopathy, erythema nodosum, fever and polyarthralgia. Excellent prognosis.
What is Mikulicz syndrome?
Enlargement of parotid and lacrimal glands due to sarcoidosis tuberculosis or lymphoma (outdated term, associated with sjogrens)
What is Heerfordts syndrome?
aka uveoparotid fever
Parotid enlargement, fever and uveitis secondary to sarcoidosis
What is granulomatosis with polyangitis?
THINK Pulmonary haemorrhage + renal impairment + flat nose (septum collapse)
This is a vasculitic disorder causing inflammation in the blood vessels in your nose, sinus, throat, lungs and kidneys (formerly called Wegeners granulomatosis
What is costochondritis?
- Inflammatory process of the costochondral or costosternal joints (usually 2nd to 5th junctions)
- Often appears after strenuous activiting
- Exacerbated by movement and deep breathing
What is Tietze’a syndrome?
- Chest pain and cartilage swelling near the upper ribs
- Can be triggered by physical trauma, recurrent respiratory infection or bad coughing fits
- Manage with rest, NSAIDs and steroids
