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Phase 2A > Respiratory > Flashcards

Respiratory Flashcards

1
Q

define COPD

A

Chronic Obstructive Pulmonary Disease

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2
Q

What two conditions come over the umbrella term COPD?

A

Emphysema and chronic bronchitis

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3
Q

What is the pathology of COPD

A

loss of alveolar attachments leading to a decrease of elastic recoil resulting in collapse of the airways. There is fibrosis and lung destruction.

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4
Q

name 2 features that are characteristic of COPD

A

airflow obstruction
usually progressive
not fully reversible
associated with enhanced chronic inflammatory response in the airways

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5
Q

name three types of cells that are associated in the chronic inflammatory response seen in COPD

A

Neutrophils, many macrophages and CD8+ T lymphocytes

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6
Q

what is emphysema?

A

enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls. Often visualised on CT.

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7
Q

What is chronic bronchitis defined as clinically?

A

defined clinically as cough, sputum production on most days for 3 months of 2 successive years.

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8
Q

Name two vascular changes you can get in COPD?

A

Poor V/Q mismatch
Low PaO2
Poor ventilation may give a high pCO2
Hypertrophy of smooth muscle cells and elastic lamina cause vasoconstriction leading to secondary pulmonary hypertension.

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9
Q

What is the aetiology of COPD?

A

smoking

need a genetic susceptibility

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10
Q

name 3 risk factors besides smoking that increase a person’s risk of having COPD?

A

Occupational dust and chemicals
Environmental tobacco smoke (passive smoking)
Indoor and outdoor air pollution
Infections and childhood infections
Socioeconomic status (+ parents = in utero development )
Ageing population

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11
Q

What can cause an acute exacerbation in COPD?

A

Can be triggered by a viral or bacterial infections

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12
Q

what are three symptoms of COPD?

A

Shortage of breath
Cough, phlegm
Wheeze

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13
Q

Name 5 signs of COPD?`

A 
Raised Respiratory Rate 
Hyperexpanded chest / barrel shaped chest 
Cyanosis 
Weight loss (caused by patients finding difficulty to coordinate breathing and chewing) 
Cor pulmonale 
   - Secondary heart failure
   - Swollen ankles 
   - Raised JVP
   - Cardiac output is maintained
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14
Q

What are the two phenotypes that illustrate the two extremes of COPD?

A

Pink puffer

Blue bloater

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15
Q

Describe a classic pink puffer

A

very breathless but not cyanosed. Have increased alveolar ventilation, breath hard. Normal PaO2 and a normal or low PaCO2. Weight loss.

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16
Q

describe a classic blue bloater?

A

Decreased alveolar ventilation. Low PaO2 and a high PaCO2. Cyanosed but not breathless. Cor pulmonale.

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17
Q

What are the symptoms of an acute exacerbation of COPD?

A

Increasing cough
Breathlessness
Wheeze
Decreased exercise capacity

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18
Q

What 6 investigations would you do in someone with COPD?

A 
Spirometry 
Full Blood Count 
Chest X-ray 
CT
ECG
COPD assessment test to assess the quality of life
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19
Q

what would a FBC show in a COPD patient?

A

increased packed cell volume

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20
Q

what would a chest x-ray show in a COPD patient?

A

Hyperinflation; flat hemidiaphragms, large central pulmonary arteries.

Also looking to see if there is any possibility of a different diagnosis e.g pneumonia or lung cancer

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21
Q

What may you be able to see on a CT scan of someone with COPD?

A

Bronchial wall thickening, scarring, air space enlargement

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22
Q

What FEV1 score is predictive of COPD?

A

less than 80%

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23
Q

What FEV1:FVC ratio is predictive of COPD?

A

less than 70%

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24
Q

What investigations would you do in someone having an acute exacerbation of COPD?

A 
ABG
CXR to exclude pneumothorax and infection
FBC, U&E, CRP
ECG
Send sputum for culture if purulent
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25
Q

what are the lifestyle interventions for COPD mamagement?

A

Smoking cessation

Regular activity

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26
Q

Name three types of medication you can use in the treatment of COPD?

A 
B2 agonist (long or short acting) 
Anticholinergic (long or short acting) 
Inhaled corticosteroid
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27
Q

what are the surgical options for treatment of COPD in certain selected patients?

A

Lung volume reduction surgery

Lung transplant

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28
Q

What is the treatment of an acute exacerbation of COPD?

A

1) Nebulized bronchodilators
2) Controlled oxygen therapy
3) Steroids
4) Antibiotics if there is evidence of infection
5) If no response consider non-invasive positive pressure ventilation or consider a respiratory stimulant drug e.g doxapram
6) If still no response may have to consider intubation and ventilation

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29
Q

What is asthma?

A

Bronchial hyperresponsiveness causing a reversible airways obstruction

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30
Q

What is the pathology of asthma?

A

Increased number of smooth muscle cells (which become hypertrophied).
Smooth muscle cells constrict, narrowing the lumen. This is triggered by many stimuli.

Mucosal swelling and inflammation caused by eosinophils in the lungs.

Increased mucus production

All three factors lead to obstruction and unventilated parts of the lung

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31
Q

how is asthma classified?

A

1) Eosinophilic or non-eosinophilic?
2) If eosinophilic is it atopic asthma or non-atopic asthma

3) if non-eosinophilic is it:
a) smoking associated
b) non-smoking, non-eosinophilic
c) obesity related

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32
Q

What is eosinophilic asthma?

A

Allergic inflammation is characterised by the recruitment of eosinophils.

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33
Q

What is atopic asthma? And name two causes?

A

Atopy is the tendency to develop IgE mediated reactions to common aeroallergens e.g cats, dust.

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34
Q

Name 4 symptoms of asthma?

A 
Episodic wheeze 
Breathlessness
Cough
Diurnal variation (asthma is worse at 3-5am in the morning probably due to a natural dip in adrenaline) 
Some may have reflux
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35
Q

Name 4 provoking factors that can make asthma worse?

A

Something you’re allergic to e.g cats, dogs etc.
Cold air
Exercise
Laugher
Can be worse just before women get period
NSAIDs
Beta blockers

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36
Q

What other atopic diseases are commonly associated and found alongside asthma?

A

Eczema
Hay fever
Allergies

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37
Q

What are three signs of asthma?

A

Physical examination may be normal as the wheeze is episodic.

Hear a wheeze that is polyphonic, can occur on expiration and inspiration and is widespread across the chest.

Hyperinflated chest

Tachypnoea

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38
Q

What are signs of an uncontolled/moderate acute asthma attack?

A

PEFR > 50%
Resp Rate < 25
Pulse < 110bpm
Normal speech

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39
Q

What are the signs of a severe asthma attack?

A

PEFR 33-50% predicted
RR > 25
Pulse > 110bpm
Inability to complete sentences

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40
Q

What are the signs of a life threatening asthma attack?

A

PEFR < 33%
SaO2 < 92%
Normal PaCO2
Altered consciousness level, exhaustion, arrhythmia, hypotension, silent chest, cyanosis

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41
Q

What aspects are important when taking a history in an asthma patient?

A

Presenting complaint

  • Work out the severity of the disease (A&E attendances, admissions, ITU care, attendance at GP for courses of antibiotics and steroids)
  • RCP3 questions for assessing severity of chronic disease
  • Recent nocturnal waking?
  • Usual asthma symptoms in day?
  • Interference with activities of daily living?
  • Age of onset
  • Associated symptoms (e.g eczema)
  • PMH
  • Drugs (make sure not on beta blockers)
  • Family and social history e.g smoking, pets in the home
  • Occupational history - work may provide the trigger if symptoms are better at weekends/holidays
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42
Q

What tests can you do to investigate chronic asthma

A

FBC
Fraction of expired Nitrous Oxide (FeNO).
Tests for atopy and allergy : skin prick test, radioallergosorbent test (RAST)
CXR
Lung Function Tests
Reversibility testing

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43
Q

What may a FBC show when investigating an asthma patient?

A

Eosinophilia

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44
Q

What does a high FeNO suggest?

A

Eosinophilic disease

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45
Q

Why may you perform a chest X-ray when investigation asthama?

A

Make sure not missing a potential cancer

Make sure not COPD

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46
Q

What may the lung function tests show in an asthma patient?

A

Airway obstruction may be present (reduced FEV1 and reduced FEV1/FVC ratio)
Peak flow - PEFR reductions from percent predicted (varied)
Increased response to challenge agents

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47
Q

What is reversibility testing and why would you use it when investigating asthma?

A

Increase in lung capacity with bronchodilators or anti-inflammatory treatment (increase of 12% in FEV1 together with increase in 200ml in volume strongly suggests asthma)

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48
Q

What tests would you do in a patient presenting with acute asthma?

A

Peak Flow
Measure oxygen level
ABGs analysis may be needed.
CXR

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49
Q

Why is a normal PaCO2 very bad in acute asthma? What needs to happen to patient?

A

Suggests that there is an increased work in breathing and lungs are not reciprocating the work needed i.e not hyperventilating

Need to get to ITU NOW!

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50
Q

What lifestyle advice can you give to asthma patients to manage their condition?

A

Stop smoking
Weight loss if overweight
Avoid precipitants
Educate to enable self management

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51
Q

Name three medications available in the treatment of asthma?

A

Bronchodilators - mainly beta2-adrenoreceptor agonists

Corticosteroids

New biologic agents

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52
Q

What is the mechanism of action of beta2-adrenoreceptors?

Give an example of a short and a long acting one?

A

Relax the bronchial smooth muscle
short acting : salbutamol
long acting: salmeterol

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53
Q

What is the benefit of having a long acting beta2-adrenorecptor agonist?

A

can help nocturnal symptoms and reduce morning dips.

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54
Q

name two side effects of salbutamol?

A

Tachyarrhythmias

Anxiety

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55
Q

What is the best way to give corticosteroids to an asthma patient? Why?

A

inhaled to prevent systemic side effects such as diabetes.

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56
Q

Name an inhaled corticosteroid?

A

Beclometasone

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57
Q

when would you use new biologics in the treatment of asthma patients?

A

These are heavily regulated.
Patient has to have severe eosinophilic uncontrolled asthma and tried several other drugs before being offered.

Very expensive!

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58
Q

Name two examples of new biologic drugs used in asthma?

A

Omalizumab (anti-IgE)

Mepolizumab (anti-IL-5)

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59
Q

what is the treatment plan in acute asthma?

A

Oxygen (40-60%) to maintain sats 94-98%.
Salbutamol nebulizer with oxygen and give prednisolone
Repeat the salbutamol if PEF remains < 75%
Monitor PEFR, oxygen, heart rate and resp rate

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60
Q

How are primary lung cancers classified?

A

Into :
Small cell lung carcinomas (20%)
Non-small cell lung carcinomas

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61
Q

Describe small cell lung carcinomas

A

High grade epithelial neoplasm with STRONG cigarette smoking association

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62
Q

What features so small cell lung carcinomas usually have?

A

often secreting polypeptide hormones resulting in paraneoplastic syndromes:

  • Secretion of PTH
  • SIADH
  • Secretion of ACTH and other hormones

The majority of SCLC are disseminated (spread beyond the chest to rest of the body) at the time of presentation

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63
Q

Describe non-small cell carcinomas?

A

Variable grade/type epithelial neoplasm with cigarette smoking association. May have metastasis by presentation/diagnosis.

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64
Q

Name three types of non-small cell carcinoma?

A

Squamous cell carcinoma
Adenocarcinoma
Large cell undifferentiated carcinoma

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65
Q

Briefly outline the pathology of primary lung carcinomas?

A

Cell dysplasia leads to carcinoma. Occurs due to a mutation, then increased cell proliferation and decreased apoptosis. These mechanisms are controlled by genes. More p53 gene expression → severe dysplasia → car

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66
Q

Name 4 cancers that commonly metastasise to the lung?

A

Breast
Colorectal
Kidney
Testicular

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67
Q

Name three causes of lung cancer?

A

Cigarette smoking
Passive smoking
Occupational risk factors: asbestos, radon, nickel, chromate, arsenic
Lung fibrosis

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68
Q

Name 5 symptoms of lung cancer?

A 
Cough
Recurrent chest infections
Haemoptysis
Increasing shortness of breath
Extra-pulmonary changes (directly/indirectly due to cancer) 
Chest pain
General malaise
Weight loss
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69
Q

Name two signs of lung cancer?

A

Cachexia

May be lung collapse or pleural effusion

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70
Q

Name 3 extrapulmonary changes that may be a sign of lung cancer?

A

Clubbing, Hypertrophic pulmonary osteoarthropathy (causing wrist pain)

Cushing’s, hypercalcaemia, gynaecomastia, dilutional hyponatremia caused by ectopic secretions

Cerebellar degeneration, myopathy, polyneuropathy

DIC

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71
Q

Name symptoms / signs of lung metastasis?

A 
Bone tenderness
Hepatomegaly
Confusion 
Fits 
Focal CNS signs 
Cerebellar syndrome 
Proximal myopathy
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72
Q

What investigations would you do in someone with suspected lung cancer?

A 
Chest X-ray 
Cytology
Fine needle aspiration/biopsy of peripheral lesions/lymph nodes
CT chest to stage the tumour
PET/CT scan to help in staging
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73
Q

What may a chest X-ray show in someone with lung cancer?

A
  • look for peripheral nodules (a mass) : increased density/whiteness in lungs
  • hilar enlargement
  • Consolidation (region of normally compressible lung tissue that has been filled with liquid instead of air)
  • Pleural effusion
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74
Q

What patients should be offered PET/CT scan?

A

all patients who may be suitable for surgery with curative intent should be offered this before treatment

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75
Q

Name two preventative things you can do to to try and prevent lung cancer?

A

Stop smoking

Prevent occupational exposure to carcinogens

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76
Q

What is the treatment for small cell lung carcinoma?

A

Chemotherapy +/- radiotherapy

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77
Q

What is the treatment of non-small cell lung carcinoma?

A
  • Lobectomy is the treatment of choice if medically fit/able. Usually smaller tumours
  • Radical radiotherapy (stage I, II, III)
  • Chemotherapy +/- radiotherapy for more advanced disease
  • May be offered new gene-based chemotherapy
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78
Q

what is mesothelioma?

A

A tumour of mesothelial cells that usually occurs in the pleura

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79
Q

What is mesothelioma associated with?

A

Associated with occupational exposure to asbestos. Latent period can be up to 45 years.

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80
Q

Name 5 signs/symptoms of mesothelioma?

A

Chest pain, dyspnoea, weight loss, finger clubbing, recurrent pleural effusions

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81
Q

What investigation would you do in mesothelioma?

A

CXR/CT

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82
Q

What would a CT/CXR show in a patient with mesothelioma

A

Pleural thickening / effusion

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83
Q

What treatment would you give to a patient with mesothelioma?

A

Chemotherapy can help improve survival

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84
Q

describe the usual pathology of PE?

A

Usually arises from venous thrombosis in the pelvis or legs.
Clot that starts in the leg and has detached, gone through the right side of the heart and become lodged in the pulmonary arteries

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85
Q

what is the main cause of pulmonary embolism?

A

Deep Vein Thrombosis

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86
Q

Name three risk factors for developing a pulmonary embolism?

A 
Recent surgery (esp hip/knee replacement) 
Thrombophilia
Leg fracture
Prolonged bed rest 
Malignancy
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87
Q

Name 5 symptoms of a pleural embolism?

A 
Acute breathlessness
Pleuritic chest pain 
May have signs/symptoms of DVT
Haemoptysis 
Dizziness
Syncope
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88
Q

Name 5 signs of a pulmonary embolism?

A 
Tachycardia 
Tachypnoea 
Pleural rub 
Cyanosis 
Severe dyspnoea 
Hypotension 
Pyrexia (fever)
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89
Q

What tests would you do to investigate a pulmonary embolism?

A 
Chest X-ray 
ECG
ABG
D-dimer
CT pulmonary angiogram
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90
Q

Why do we do a chest x-ray when investigating a pulmonary embolism?

A

May be normal.
CXR is normally done to look for signs of pneumonia
May show a dilated pulmonary artery or small pleural effusion

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91
Q

What would an ABG show of someone who has a pulmonary embolism?

A

Type 1 respiratory failure

Decreased PaO2 and decreased PaCO2

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92
Q

What test is diagnostic in PE?

A

CT pulmonary angiogram

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93
Q

What is the treatment for a pulmonary embolism?

A

Clot lysis
Haemodynamically unstable: IV altepase
Haemodynamially stable: LMWH, then start DOAC/warfarin

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94
Q

What preventative actions can you take to reduce the risk of PE?

A

Early mobilisation if in surgery
Compression stockings
Heparin to all immobile patients

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95
Q

What is the difference between active and latent TB?

What is the differing natural history?

A
  • Active disease
    Local immune response is not enough to control the disease. Bacilli and macrophages continue to come together to form granulomas (primary Ghon focus). The granuloma slowly enlarges and the middle becomes necrotic, it continues to grow until it becomes a cavity. Can spread to the lymph nodes. Active TB disease can arise from primary infection or reactivation of previously latent disease.
  • Latent TB Disease
    An infection without disease due to the persistent immune system containment (granuloma formation prevents bacteria growth and spread). Patient is asymptomatic and non-infectious. 1 in 10 people who have latent disease, the TB will reactivate and cause active disease (post primary disease)
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96
Q

What is the cause of TB?

A

Mycobacterium tuberculosis

97
Q

How is TB spread?

A

Catch as the bacteria is spread in aerosol from infected individuals lungs to another lung via spitting, sneezing.

98
Q

Name an alternative method for catching TB?

A

Can also get TB caused by Mycobacterium bovis which is bovine TB by drinking milk with it in.

99
Q

Name three risk factors that increase a person’s likelihood for developing TB?

A 
Born in high prevalence areas 
IVDU
Homeless
Alcoholic 
Prisons
HIV positive
100
Q

What are the systemic features of TB?

A 
Weight loss
Low grade fever
Anorexia 
Night sweats
Malaise
101
Q

What are the Pulmonary features of TB?

A

Persistent cough (more than 3 weeks)
Chest pain
Breathlessness
Haemoptysis
Lung consolidation
Collapse (caused by obstruction in bronchus)
Pleural effusion (cavity erodes into the pleura, causing fluid to enter the lungs and build up)

102
Q

What is tuberculosis lymphadenitis?

A

Painless enlargement of cervical or supraclavicular lymph nodes

103
Q

What organs/parts of the body can TB commonly affect (other than lungs)

A 
Abdomen
Spine
CNS
GU 
Cardiac
104
Q

Outline features of abdominal TB?

A

Ascites,
abdominal lymph nodes,
ileal malabsorption,
colicky abdominal pain

105
Q

2 features of spinal TB?

A

Pain or swelling of joint, Pott’s disease with spinal cord lesion

106
Q

What is miliary TB?

A

Bacteria spreads throughout the lung forming tiny granulomas that can be seen as tiny spots on a chest x-ray.

107
Q

What problems can TB cause if it gets into the CNS?

A

TB meningitis

Formation of tuberculomas

108
Q

Name 4 features of GU TB?

A

Epididymitis, frequency, dysuria and haematuria

109
Q

What can cause cardiac TB?

A

Can get erosion from the lymph nodes into the pericardium, when infection spreads can cause a pericardial effusion.

110
Q

What are the tests for active TB?

A 
Chest X-ray
Blood tests
Sputum smear!!
Sputum culture
Nucleic acid amplification test 
Biopsy specimen
111
Q

what may a CXR show in active TB disease?

A

Fibronodular/linear opacities in the upper lobe

112
Q

What blood tests would you do in TB and what could they show?

A

FBC : normochromic normocytic anaemia
Raised ESR/CRP
Hypergammaglobulinemia
Hypercalcaemia

113
Q

What stain do you use for TB microscopy?
What does look for?
What is an alternative? What are the benefits of this stain?

A

ZIEHL NEELSEN
- Stains acid fast bacilli pink

Auramine phenol

  • fluorescent stain
  • faster and more sensitive
114
Q

What tests would you do for detecting latent TB?

A

Tuberculin skin testing (Mantoux test)

  • this is an intradermal injection of purified protein from TB
  • skin reaction used to determine if patient has had past exposure to TB
  • Positive inflammatory response = positive test

Interferon-gamma release assay
- diagnose exposure to TB by measuring the release of interferon-gamma from T cells reacting TB antigen

115
Q

What is a disadvantage of Mantoux test?

A

Cannot differentiate between BCG vaccine or if latent TB

116
Q

What is an advantage of interferon-gamma release assay

A

Increase specificity compared to mantoux test if there is a history of BCG vaccination

117
Q

what is the treatment for active TB?

A

Pyrazinamide + ethambutol (only first 2 months)

Rifampicin + isoniazid (all 6 months)

Notify public health england

118
Q

What is the treatment for latent TB?

A

Balance risk of developing active disease with possible side effects.
Increased risk: HIV, transplantation, chemotherapy, diabetes, CKD,
3 months isoniazid + rifampicin OR 6 months isoniazid

119
Q

Name three preventative methods used to reduce the risk of infection of TB?

A

Active case finding - make non infectious to reduce incidence
Detection and treatment of latent TB
Vaccination : given to neonates from high risk groups and those more at risk for coming into contact e.g healthcare workers.

120
Q

What is drug resistant TB defined as?

A

Multi Drug resistance = rifampicin and isoniazid

Most common single drug resistance is isoniazid

121
Q

What is the pathology of pneumonia?

A

Bacteria from the upper respiratory tract get micro aspirated into the lung.
Macrophage engulfs but can become overwhelmed if there is an increase in bacteria.
Inflammatory cytokines recruit neutrophils to the area.
This means that the endothelial lining of the blood vessel has to open to allow cells in so fluid also may enter the alveolus. Neutrophils will die and this will form pus which is what is coughed up and prevents gas exchange.

122
Q

What is the classification of pneumonia?

A

Community acquired pneumonia.
Hospital acquired
Aspiration
Immunocompromised patients

123
Q

What are the typical organisms that cause pneumonia?

What are the features of the bacteria which the most common cause of pneumonia?

A

Streptococcus pneumoniae : most common. Gram positive cocci. Alpha haemolysis. Optochin sensitive

Haemophilus influenzae: Gram negative coccobacilli

Staph. Aureus : ventilator-associated pneumonia

124
Q

Name the 4 atypical organisms that can cause pneumonia?

A

Mycoplasma pneumoniae
Legionella pneumophila
Chlamydia pneumonia
Coxiella burnetii

125
Q

Name three groups of people who are at a higher risk of catching pneumonia?

A 
Infants and elderly 
COPD and other chronic lung disease 
Immunocompromised 
Nursing home resident 
Impaired swallowing (e.g from a neurological condition) 
Diabetes
Congestive heart disease
Alcoholics and IV drug users
126
Q

Name 5 symptoms of pneumonia

A

Fever, sweats, rigors (generic infection response)
Cough
Sputum (classically rusty sputum suggests S.pneumonia)
Short of breath
Pleuritic chest pain particularly S.pneumonia

Systemic feature
Weakness, malaise, tiredness

127
Q

Name 5 signs of pneumonia?

A 
Abdominal vital signs (related to infection, the more present and greater they are suggests a larger severity) 
Raised heart rate 
Raised respiratory rate 
Low blood pressure
Fever
Dehydration
128
Q

What are 5 signs of lung consolidation on percussion and auscultation in pneumonia?

A

Dull to percussion
Decreased air entry
Bronchial breath sounds
Crackles +/- wheezes - due to pus in alveolar when breathing in
Increased vocal resonance
+/- hypoxia and signs of respiratory failure especially if chronic lung disease or severe pneumonia

129
Q

What investigations would you do in suspected pneumonia?

A 
Chest X-Ray 
FBC
Biochemistry
C-reactive protein 
Pulse oximetry
Sputum
Blood cultures 
Urine
Always check for HIV
130
Q

What a CXR show on a patient with pneumonia?

A

Lobar or multilobar infiltrates, cavitation or pleural effusion

131
Q

Why would you test urine in a pneumonia patient?

A

Check for Legionella/pneumococcal urinary antigens

132
Q

How do you assess the severity of pneumonia in a patient?

A 
CURB65
- Confusion 
- Urea > 7mmol/L
- Resp rate > 30/min
-Blood pressure ; low
- Age > 65
Each scores one. 
0-1 : PO antibiotic, home treatment 
2 : hospital therapy 
3+ : severe pneumonia indicates increased mortality risk - ITU consider
133
Q

What antibiotics would you use to treat a patient with S.pneumoniae pneumonia?

A

Amoxicillin, cefuroxime or cefotaxime

134
Q

What antibiotics would you use to treat a patient with H. influenzae pneumonia?

A

Co-amoxiclav

135
Q

What antibiotics would you use to treat patients with Staph aureus pneumonia?

A

Flucloxacillin or Vancomycin if MRSA

136
Q

What antibiotics would you use to treat patients with atypical organisms causing pneumonia?

A
  • Macrolides (erythromycin, clarithromycin)
  • Fluoroquinolones (ciprofloxacin)
  • Tetracyclines (doxycycline)
137
Q

What 4 complications can you develop from pneumonia?

A
  • Type I respiratory failure
  • Hypotension (may be due to a combination of dehydration and vasodilation due to sepsis)
  • Atrial fibrillation. Usually resolves with treatment of the pneumonia
  • Pleural effusion, inflammation of the pleura by adjacent pneumonia may cause fluid exudation into the pleural space
  • Empyema : pus in the plural space.
  • Lung abscess : cavitating area of localized, suppurative infection within the lung
  • Sepsis
138
Q

What are upper respiratory tract infections?

A

Self limited irritation and swelling of the upper airways with associated cough with no proof of pneumonia.

These infections can involve the nose, sinuses, pharynx, larynx and large airways.

Direct invasion of the upper airway mucosa by the organism.

139
Q

Name four types of virus that cause upper respiratory tract infections?

A 
Rhinoviruses (45-50%) 
Influenza A virus (25-30%) 
Coronaviruses (10-15%) 
Adenoviruses (5-10%) 
Parainfluenza viruses (5%)
140
Q

Name three risk factors that increase the likelihood of developing a viral upper respiratory tract infection?

A
  • Close contact with children
  • Medical disorder e.g people with asthma and allergic rhinitis
  • Smoking
  • Immunocompromised
  • Anatomical anomalies including facial dysmorphic changes or nasal polyposis increases the risk
141
Q

Name 5 symptoms of a upper respiratory tract infection?

A 
Cough 
Sore throat
Runny nose
Nasal congestion 
Headache
Low-grade fever
Facial pressure
Sneezing 
Malaise
Myalgias
142
Q

How do you diagnose an upper respiratory tract infection?

A

The presence of classical features of a rhinovirus infection coupled with the absence of signs of bacterial infection or serious respiratory illness is sufficient to make the diagnosis of the common cold. No testing necessary.

143
Q

What is the treatment for upper respiratory tract infections?

A

Symptom relief
Decongestants

Early antiviral treatment for influenza infection shortens the duration of the influenza symptoms

144
Q

What is interstitial lung disease?

A

group of lung diseases affecting the interstitium (the tissue and space around the alveoli)

145
Q

What is the pathophysiology of idiopathic pulmonary fibrosis?

A
  1. Fibroblasts try to repair damaged lung tissue
  2. Fibroblasts migrate to the lungs and become myofibroblasts
  3. These myofibroblasts deposit collagen within the extracellular matrix of the lung
  4. Fibroblasts are resistant to apoptosis
  5. Myofibroblasts proliferate and form fibroblastic foci
  6. Leads to thickened tissue causing a lower gas exchange efficiency in the lungs (decreased DLCO)
146
Q

Name 5 symptoms of idiopathic pulmonary fibrosis?

A 
Dry cough
Exertional dyspnoea
Malaise
Weight loss
Arthralgia
147
Q

Name 3 signs of idiopathic pulmonary fibrosis?

A

Cyanosis
Finger clubbing
Fine end-inspiratory crepitations

148
Q

What investigations would you do for idiopathic pulmonary fibrosis?

A 
High resolution CT scanning !!
Lung biopsy 
Spirometry
Diffusing capacity of lung for CO
Exercise testing
149
Q

What does a HR CT scan show if the patient has idiopathic pulmonary fibrosis?

A

Shows honeycombing and thickening of the alveoli. Predominantly affects the outside and the bases of the lung. Can see a thickened dilated bronchus (traction bronchi)

150
Q

What will spirometry of a patient with idiopathic pulmonary fibrosis patient show?

A

restrictive lung disease

FVC shows restriction of lung volume

151
Q

What does the diffusing capacity of the lungs for CO show in a patient with idiopathic pulmonary fibrosis?

A

Reduction in gas transfer exchange

152
Q

What does exercise testing show in a patient with idiopathic pulmonary fibrosis?

A

Shows hypoxia on exertion and a reduction in exercise capacity
- incremental shuttle walk test or 6 minute walk test

153
Q

what is the treatment for idiopathic pulmonary fibrosis? Name 2 side effects for each medication?

A

Pirfenidone (inhibitor of growth factor-beta and slows down the ability of fibroblasts to damage the lungs. SE = photosensitivity and GI upset

Nintedanib SE = diarrhoea and GI upset

154
Q

What is the palliative treatment for idiopathic pulmonary fibrosis?

A

Commonly patients will experience symptoms from ILD which do not resolve with treatment of disease
Opioids for breathlessness and pain
Anxiolytics for anxiety (benzodiazepines)
Oxygen therapy

155
Q

What is sarcoidosis?

A

Multisystem granulomatous disorder

90% of cases affect the lungs

156
Q

What is the aetiology of sarcoidosis?

A

Unknown

Associated with HLA-DQB1 and DBQ1 alleles

157
Q

What are the symptoms of acute sarcoidosis?

A

Fever
Erythema nodosum (swollen fat under the skin causing red bumps)
Polyarthralgia
Bilateral hilar lymphadenopathy

(in 20-40% of cases the disease is discovered incidentally after a routine CXR and so is asymptomatic)

158
Q

What are the features of pulmonary disease sarcoidosis?

What are the symptoms?

A

Bilateral hilar lymphadenopathy
May be pulmonary infiltrate or fibrosis

Symptoms: dry cough, progressive dyspnoea, decreased exercise tolerance and chest pain

159
Q

Name 4 non-pulmonary signs of sarcoidosis?

A 
Lymphadenopathy 
Hepatomegaly 
Splenomegaly 
Conjunctivitis 
Glaucoma 
Neuropathy 
Many others p. 196
160
Q

What investigations should you do for sarcoidosis?

A 
Bloods
Chest X-ray 
ECG
Lung Function Tests
Tissue biopsy
Bronchoalveolar lavage
161
Q

What may the bloods of a patient with sarcoidosis show ?

A

Increased ESR

Lymphocytopenia

162
Q

What are the stages of sarcoidosis as seen on a chest x-ray

A

Stage 0: normal
Stage 1: BHL
Stage 2: BHL + peripheral pulmonary infiltrates
Stage 3: peripheral pulmonary infiltrates alone
Stage 4: progressive pulmonary fibrosis, bulla formation (honeycombing)

163
Q

What test is diagnostic for sarcoidosis and what does it show?

A

Tissue biopsy

Shows non-caseating granulomata

164
Q

What may lung function tests show for a patient with sarcoidosis?

A

May be normal or show reduced lung volumes, impaired gas transfer and a restrictive ventilatory defect

165
Q

What is the treatment for sarcoidosis?

A

Patients with BLH ususally don’t need treatment and will resolve on their own

Acute sarcoidosis : rest and NSAIDs

Corticosteroids in some cases

166
Q

What is bronchiectasis ?

A

Chronic inflammation of the bronchi and bronchioles leading to permanent dilation and thinning of these airways

167
Q

What are causes of bronchiectasis?

A 
Main organisms 
H. influenzae
Strep. Pneumoniae
Staph. Aureus 
Pseudomonas aeruginosa

Congenital causes
CF
Young’s syndrome

Post-infection 
Measles
Pertussis
Bronchiolitis
Pneumonia
TB
HIV

Other
Bronchial obstruction e.g tumour, foreign body
Allergic bronchopulmonary aspergillosis

168
Q

Name three symptoms of bronchiectasis?

A

Persistent cough
Copious purulent sputum (contains pus)
Intermittent haemoptysis

169
Q

Name three signs of bronchiectasis?

A

Finger clubbing
Coarse inspiratory crepitations
Wheeze

170
Q

What tests would you do in a patient for bronchiectasis?

A 
Sputum culture
Chest X-rays 
CT chest 
Spirometry
Bronchoscopy
171
Q

What would the CXR show of a patient with bronchiectasis?

A

Cystic shadows
Marked abdominal dilatation of the airways
Thickened bronchial walls

172
Q

What is the treatment of bronchiectasis?

A

Airway clearance techniques and mucolytics

  • chest physiotherapy
  • flutter valve may aid sputum expectoration and mucus drainage

Antibiotics that are sensitive to the organism found in sputum culture

173
Q

What antibiotics do you use to treat Streptococcus pneumoniae?

A

Amoxicillin
Cefuroxime
Cefotaxime

174
Q

What antibiotics do you use to treat H. influenzae?

A

Co-amoxiclav

175
Q

What antibiotics to you use to treat Staph. aureus?

A

Flucloxacillin

176
Q

What antibiotic do you use to treat MRSA?

A

Vancomycin

177
Q

What antibiotic do you use to treat Pseudomonas aeruginosa

A

oral ciprofloxacin

178
Q

What is the pathology of cystic fibrosis?

A

Mutation in Cl- channel. Defect leads to a combination of defective chloride secretion and increased sodium absorption across airway epithelium. The changes in the composition of airway surface liquid predispose the lung to chronic pulmonary infections and bronchiectasis.

Increased thickness in mucosal secretions.

179
Q

Aetiology of cystic fibrosis?

A

Mutations in the CF transmembrane conductance regulator (CFTR) gene on chromosome 7.

Autosomal recessive inheritance

180
Q

What are the symptoms of cystic fibrosis in a neonate?

A

Failure to thrive
Meconium ileus (bowel obstruction caused by meconium in child’s intestine to be thicker and stickier than normal)
Rectal prolapse

181
Q

Name 5 symptoms relating to the respiratory system of cystic fibrosis in children/young adults?

A 
Cough 
Wheeze
Recurrent infections 
Bronchiectasis
Pneumothorax
Haemoptysis
Respiratory failure 
Cor pulmonale
182
Q

Name 3 GI symptoms of cystic fibrosis in children/young adults?

A

Pancreatic insufficiency
Distal intestinal obstruction syndrome
Gallstones
Cirrhosis

183
Q

Name three signs of cystic fibrosis?

A

Cyanosis
Finger clubbing
Bilateral coarse crackles

184
Q

What tests do you do to diagnose cystic fibrosis?

A 
Neonatal heel prick test (blood spot immunoreactive trypsin test) 
Sweat test! 
Genetic testing 
Bloods
Chest X-ray
Spirometry : obstructive
185
Q

What is the sweat test? What result shows cystic fibrosis is a very likely diagnosis?

A

Sweat sodium and chloride. Measure the concentration.

Conc. > 60mmol/L = CF is likely to be diagnosed

186
Q

What is the management for respiratory symptoms in cystic fibrosis?

A

Physiotherapy (postural drainage, airway clearance techniques)
Antibiotics given for acute infection exacerbations and prophylactically
Mucolytics e.g rhDNase
Bronchodilators

187
Q

What treatment may be needed in advanced lung disease?

A

Oxygen
Diuretics
Non-invasive ventilation
Lung or heart/lung transplantation

188
Q

What immunomodulatory agent may be used to treat people with cystic fibrosis?

A

used for people with deteriorating lung function

Azithromycin

189
Q

What is pleural effusion?

A

Fluid in the pleural space

190
Q

How are pleural effusions classified?

A

Divided by their protein concentration into transudates (<25g/L) and exudates (>35g/L)

191
Q

What is a cause of transduate pleural effusion?

A
  • Increased venous pressure (cardiac failure, constrictive pericarditis, fluid overload)
  • Hypoproteinemia (cirrhosis, nephrotic syndrome, malabsorption)
192
Q

What is a cause of exudate pleural effusion?

A

increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy
Pneumonia, TB, pulmonary infection, rheumatoid arthritis

193
Q

Name 2 symptoms of pleural effusion?

A

Asymptomatic

Or dyspnoea, pleuritic chest pain

194
Q

Name 5 signs of pleural effusion?

A

Decreased expansion on the affected side
Stony dull percussion note on the affected side
Diminished breath sounds on the affected side
May be bronchial breathing above the effusion where the lung is compressed
With large effusions there may be tracheal deviation away from the effusion

195
Q

What three investigations would you do for a pleural effusion? Which is diagnostic?

A

Chest X-ray
Ultrasound
Diagnostic aspiration

196
Q

What would a CXR show of a patient with pleural effusion?

A

large effusions are seen as water-dense shadows with concave upper borders.

Smaller ones blunt the costophrenic angles

197
Q

what do you test the pleural fluid for in a pleural effusion?

A

Draw off 10-30mL of pleural fluid and send to the lab for clinical chemistry, bacteriology, cytology and immunology if indicated

198
Q

What is the management of a pleural effusion? (4)

A

Management is of the underlying cause

Drainage (if effusion is symptomatic drain it repeatedly if needed)

Pleurodesis with talc may be helpful for recurrent effusions. It adheres your lung to your chest wall. It seals up the space between the outer lining of your lung and chest wall (pleural cavity) to prevent fluid or air from continually building up around your lungs

Surgery if persistent

199
Q

What is the difference between a pneumothorax and a tension pneumothorax?

A

A pneumothorax is a collection of air within the pleural space in between the lung (visceral pleura) and the chest wall (parietal pleura) that can lead to partial or complete pulmonary collapse

Tension pneumothorax: life-threatening variant of pneumothorax characterized by progressively increasing pressures within the chest and cardiorespiratory compromise

200
Q

What is the pathology of a pneumothorax?

A

Increased intrapleural pressure → alveolar collapse → decreased V/Q ratio and increased right-to-left shunting

201
Q

What is the pathology of a tension pneumothorax?

A

In tension pneumothorax there is disrupted visceral pleura, parietal pleura or tracheobronchial tree → air enters the pleural space on inspiration but cannot exit → progressive accumulation of air in the pleural space and increasing pressure within the chest → collapse of ipsilateral lung and compression of contralateral lung, trachea, heart and SVC → imparied resp function and reduced venous return to the heart and reduced CO

202
Q

What are the causes of pneumothorax?

A

Primary
- pontaneous due to rupture of a subpleural bullae (focal regions of emphysema with no discernible wall). Especially the case in young, thin, men

Secondary
- complication of an underlying disease
COPD, asthma, carcinoma, connective tissue disorder

203
Q

name three symptoms of pneumothorax?

A

Can be asymptomatic (esp in fit young people with small pneumothoraces)
Sudden onset of dyspnoea and/or pleuritic chest pain
Ipsilateral chest pain

204
Q

Name 3 signs of a pneumothorax?

A

Reduced expansion
Hyper resonance to percussion
Diminished breath sounds on the affected side
Patient will be very unwell

205
Q

Name 5 signs of a tension pneumothorax?

A
  • Respiratory distress
  • Tachycardia
  • Hypotension
  • Distended neck veins
  • Trachea deviated away from side of pneumothorax
  • Hemodynamically unstable
  • Cyanosis
  • Restlessness
    Reduced chest expansion on the ipsilateral side
206
Q

What 2 investigations would you do for a pneumothorax?

A

Chest X-ray

ABGs

207
Q

what would you NOT do in a suspected tension pneumothorax

A

Chest X-ray

208
Q

What type of chest x-ray would you order for a pneumothorax and what may it show?

A

Expiratory film

Look for an area devoid of lung markings, peripheral to the edge of the collapsed lung

209
Q

What treatment would you do for a primary pneumothorax?

A

If SOB + rim of air > 2cm on CXR
Aspiration
If unsuccessful then chest drain

210
Q

What treatment would you do for a secondary pneumothorax?

A

SOB OR rim of air > 2cm on CXR
Chest drain
If smaller size then aspiration, if unsuccessful then chest drain

211
Q

What immediate treatment would you do for a tension pneumothorax?

A

Insert large bore needle into the 2nd intercostal space in the midclavicular line on the side of the suspected pneumothorax
Then insert a chest drain

212
Q

Define pulmonary hypertension

A

Increase in the mean pulmonary arterial pressure > 25 mmHg at rest

213
Q

Name 5 causes of pulmonary hypertension?

A
  • Idiopathic
  • Heritable (autosomal dominant inheritance)
  • Drug and toxin induced
  • Associated with HIV infection, portal hypertension, congenital heart disease, certain connective tissue disorders
  • PH due to lung diseases and/or hypoxia e.g COPD, interstitial lung disease
  • After a PE
  • PH due to left heart disease
214
Q

Name 4 symptoms of pulmonary hypertension?

A

Progressive breathlessness
Weakness
Tiredness
Exertional dizziness and syncope may also develop

Oedema and ascites tend to occur late in the disease

215
Q

Name three clinical signs of pulmonary hypertension

A

Right ventricular heave
Loud pulmonary second heart sound
Raised JVP

216
Q

What investigations would you do for pulmonary hypertension?

A 
Right heart catheterisation 
Liver Function Tests
TFTs
CXR
Pulmonary function tests
Lung biopsy may be needed to exclude interstitial lung disease
Echocardiography 
High resolution CT
MRI
217
Q

What confirms a diagnosis of pulmonary hypertension

A

Right heart catheterisation is needed to confirm the diagnosis by directly measuring pulmonary pressure

218
Q

What would be the treatment for pulmonary hypertension?

A 
Treat underlying condition 
Cardio Supportive therapy 
Prostacyclin analogues 
Endothelian-A receptor antagonists 
Phosphodiesterase-5 inhibitors
219
Q

What is the pathology of hypersensitivity pneumonitis / extrinsic allergic alveolitis?

A
  1. Encounter the antigen (allergen) : there is no reaction. Prior sensitisation.
  2. IgG antibodies develop against this antigen, produced by lymphocytes.
  3. On secondary exposure, IgG antibodies will recognise the antigen and react forming antigen-antibody complexes.
  4. These deposit in lungs and are not adequately cleared causing lung damage.
  5. Repeated exposure leads to repeated symptoms which leads to repeated damage.
220
Q

What type of hypersensitivity reaction is hypersensitivity pneumonitis?

A

Type III

221
Q

Name some common causes of hypersensitivity pneumonitis?

A

Inhalation of allergens in sensitized individuals. Common causes:

Proteins in bird droppings (bird-fancier’s lung)
Farmer’s and mushroom worker’s lung
Malt worker’s lung
Bagassosis or sugar worker’s lung

222
Q

Name 4 symptoms of acute hypersensitivity pneumonitis?

A 
Fever
Rigors
Myalgia
Dry cough
Dyspnoea
223
Q

What would you hear on ausculation of someone with acute hypersensitivity pneumonitis

A

Fine bibasal crackles (abnormal sounds from the base of the lungs)

224
Q

What are 5 features of chronic hypersensitivity pneumonitis?

A 
Finger clubbing 
Increasing dyspnoea
Weight loss 
Exertional dyspnoea
Type I respiratory failure
Cor pulmonale
225
Q

What 2 investigations would you do in acute hypersensitivity pneumonitis?
What may they show?

A

Bloods

  • neutrophilia
  • raised ESR
  • specific blood IgG levels may be useful to show that there has been previous exposure

Lung function tests
- reversible restrictive defect

226
Q

What investigations would you do for chronic hypersensitivity pneumonitis?

A 
Blood tests 
Serum antibodies 
CXR
CT chest 
Bronchoalveolar lavage
227
Q

What is useful in using bronchoalveolar lavage as an investigation for hypersensitivity pneumonitis?

A

detects increased lymphocytes (useful from distinguishing from other ILDs)

228
Q

what is the treatment for hypersensitivity pneumonitis?

A

Identification and removal of antigen

Steroids for acute/subacute disease

229
Q

What are occupational lung disorders?

A

They represent a wide-range of respiratory conditions caused by inhaling a harmful substance in the workplace

Inhalable particles, gases and vapours are generated from a wide range of industrial processes

230
Q

Name 4 conditions which come under occupational lung disorders

A

Occupational asthma
Asbestosis
Coal worker’s pneumoconiosis
Silicosis

231
Q

What types of inhalable particles can cause occupational lung disorders?
And name an example for each when you could inhale them?

A

Dust - cutting wood
Fumes - colophony fume from soldering electronics or welding fume generated by heating metal components to join
Mists - metalworking fluid mist
Inhaled vapours and gases-paint spraying (isocyanate vapours)

232
Q

What can cause occupational asthma? (3)

A 
wood
flour
metal
working fluids
isocyanate paint
233
Q

what are the symptoms of ocupational asthma?

A 
These diseases develop after an asymptomatic or latent period 
Shorter latency (months or a few years) commonly present whilst an individual worker is still exposed to a harmful material in the workplace
Longer latency (often decades) commonly present close to or after retirement

Deteriorating symptoms of work related asthma
Improves when away from work

234
Q

What are the symptoms/signs of asbestosis?

A

progressive dyspnoea
clubbing
fine end inspiratory crackles
Pleural plaques

235
Q

what are the symptoms of coal worker’s pneumoconiosis?

A

asymptomatic

co-existing chronic bronchitis is common

236
Q

what are the clinical features of silicosis?

A

progressive dyspnoea

CXR shows diffuse miliary or nodular pattern in upper and mid zones and egg shell calcification of hilar nodes

237
Q

what tests would you do in suspected industrial dust diseases?

A

CXR

Lung function tests

238
Q

what is the treatment for occupational lung diseases?

A

Avoid exposure

Symptomatic treatment for asbestosis

Can usually claim for compensation

239
Q

How can you prevent occupational lung diseases?

A
  • Legal requirement under COSHH
  • Risk assessment
  • Prevent or minimise exposures to harmful substances
    • Elimination (asbestos)
    • Substitution (latex to nitrile gloves)
    • Engineering controls (exhaust ventilation)
      RPE (masks and respirators)

Phase 2A (11 decks)

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