Respiratory Flashcards
1
Q
What are the main URTI syndromes?
A
- Common cold (rhinitus, sinusitis)
- Sore throat ( pharyngitis, tonisllitis)
- Influenza
2
Q
Main features of viral URTIs?
A
- Sore throat
- Cough
- Otalgia
- Blocked nose and rhinorrhoea
- Mild fever
3
Q
Main viral causative organisms of common cold?
A
- Rhinoviruses
- Corona viruses (!)
- Other: Coxsackie viruses, echoviruses, parainfluenza, RSV, influenza C
4
Q
Main viral causative organisms of pharyngitis/tonsillitis?
A
- Adenoviruses
- Epstein-Barr virus
- Other: Influ A,B,C, parainfluenza virus
5
Q
Main viral causative organisms of influenza?
A
- Influenza A and B
6
Q
What are the main syndromes of LRTIs?
A
- Croup - laryngotracheobronchitis
- Acute bronchitis
- Chronic bronchitis
- Bronchiolitis
- Pneumonia
7
Q
Main viral causative organisms of Croup?
A
- Parainfluenza virus
- Other: Influ A and B, RSV, Coxsackie
8
Q
Main viral causative organisms of Acute bronchitis?
A
- Adenoviruses
- Other: RSV, rhinoviruses, measles virus, influ a and b
9
Q
Main viral causative organisms of chronic bronchitis?
A
- RSV
- Rhinoviruses
- Parainfluenza viruses
10
Q
Main viral causative organisms of bronchiolitis?
A
- RSV
- Adenoviruses
- Other: Parainfluenza
11
Q
Main viral causative organisms of pneumonia?
A
- Adenoviruses
- Influ A and B
- Measles virus
- VZV
- CMV
12
Q
What is flu?
A
- An acute respiratory illness caused by infection with influenza viruses
13
Q
Different types of influenza virus?
A
A - Affects all sorts of animals. Causes severe and extensive outbreaks and pandemics.
B - Causes sporadic, less severe, outbreaks. Eg care homes, garrisons
C - Relatively minor disease
14
Q
Symptoms of flu?
A
- Upper and/or lower resp tract symptoms
- Fever
- Headache
- Myalgia
- Weakness
- Risk of 2ndary bacterial pneumonia
15
Q
What is pneumonia?
A
- Inflammation of the lung parenchyma
16
Q
Causes of pneumonia?
A
- bacterial pneumonia (common)
- viral
- fungal
17
Q
Main bacteria causing pneumonia?
A
- Streptococcus pneumoniae
- Haemophilus influenzae
- Staphylococcus aureus
- Mycoplasma pneumoniae
- Legionella pneumophilia
- Klebsiella pneumoniae
- Pneumocystis jiroveci
18
Q
Features of pneumococcal pneumonia?
A
- 80% of cases
- Ass w/ : High fever, rapid onset, pleuritic chest pain, herpes labialis
- Vaccine available
19
Q
Who does haemophilus influenzae commonly affect?
A
- Pt with COPD
20
Q
When does S. Aureus pneumonia commonly occur?
A
- Often occurs in patients following influenza infection
21
Q
What are the features of mycoplasma pneumonia?
A
- One of the atypical pneumonias
- Often presents with a dry cough and atypical chest signs/XR findings
- Autoimmune haemolytic anaemia and erythema multiforme may be seen
22
Q
Features of legionella pnia?
A
- Atypical
- Hyponatraemia and lymphopenia common
23
Q
Who often gets klebseilla pneumonia?
A
Alcoholics
24
Q
What are the features of pneumocystis pneumonia?
A
- Typically seen in HIV patients
- P/w: Dry cough, exerise-induced desaturations, absence of chest signs
25
What is idiopathic interstitial pneumonia?
- Group of non-infective causes of pneumonia
26
Which groups are at risk of pneumonia?
- Infants and the elderly
- COPD and other chronic lung disease (CF, bronchiectasis)
- Immunocompromised
- Nursing home residents
- Impaired swallow
- Diabetes
- Congestive heart disease
- Lifestyle: smokers, alcoholics, drug users
- Iatrogenic - eg long term steroids
27
Symptoms of pneumonia?
- Cough
- Sputum
- Dyspnoea
- Chest pain - may be pleuritic
- Fever
28
What are the signs of pneumonia?
- Signs of systemic inflam response: Fever, tachycardia
- Reduced O2 sats
- On exam:
- Reduced breath sounds
- Bronchial breathing
- Crackles/ consolidation
- +/- wheeze
- Dull to percussion
- decreased air entry
29
Pneumonia investigations?
- CXR: Shows consolidation
- Bloods:
- FBC - neutrophilia in bacterial infections
- U&E
- CRP
- ABG
- Blood and sputum cultures
- CRP monitoring for admitted pts
30
Management principles for pneumonia?
- Antibiotics
| - Supportive care: O2, IV fluids
31
What is risk tool for pneumonia?
| What is it made up of?
```
CURB-65
Confusion (AMT<8/10)
Urea >7
Resp rate >30
Blood pressure <90 sys and/or <60dia
>65
```
0 low risk
1-2 intermediate
3-4 high risk
32
Other markers of severe pneumonia?
- CXR – more than one lobe involved
- PaO2 <8 kPa
- Low albumin
- White cell count <4x10^9 or >20x10^9
- Blood culture positive
33
Treatment of low-severity CAP ?
- Amoxicillin first line
- If allergic give - macrolide (azith, clarith, erith) or tetracycline
- 5days course
34
Moderate severity CAP tx?
- Dual abx therapy with amoxicillin and a macrolide
| - 7-10day course
35
High severity CAP tx?
- Consider Co-Amoxiclav and a macrolide
36
Indications for pneumocooccal vaccine?
- >65 years
- Splenic dysfunction
- Immunocompromised
- Chronic medical condition
- Protects against invasive pneumococcal disease but not pneumonia
37
Most common infecting organisms in HAP?
- Gram negative enterobacteria
- Staph Aureus
- Also: Pseudomonas, Klebsiella, Bacterioles, Clostridia
38
How is HAP managed?
- Aminoglycoside antibiotic (eg. gentamycin, neomycin)
| - + Antipseudomonal penicillin IV or 3rd gen cephalosporin
39
What is aspiration pneumonia?
- Pneumonia that develops as a result of foreign materials gaining entry to the bronchial tree
- Usually oral or gastric contents such as food and saliva
- Depending on the acidity of the aspirate, a chemical pneumonitis can develop, as well as bacterial pathogens adding to the inflammation
40
Causes of aspiration pneumonia?
```
Impaired swallow:
- Neuro disease: MND, MG, bulbar palsy, huntingtons
- Stroke
- MS
- Intoxication
- Oesophageal disease: Achalasia, reflux
Iatrogenic cause:
- Intubation
```
41
Risk factors for asp pnia?
- Poor dental hygeine
- Swallowing difficulties
- Prolonged hospitalization or surgical procedures
- Impaired consciousnes
- Impaired mucociliary clearance
42
Bacteria often found in aspiration pneumonia?
- S Pneumonia
- S Aureus
- Haem Influenzae
- Pseudomonas aerugionsa
43
Treatment of aspiration pneumonia?
- IV cephalosporin
| - + IV metronidazole
44
What is bronchitis?
- Inflammation of the mucous membrane in the bronchial tubes
| - Typically causes bronchospasm and coughing
45
Cause of bronchitis?
- Usually viral
| - can be bacterial: H. Influenzae, S. Pneumoniae
46
How does bronchitis present?
- Cough can be productive or non-productive
- SOB and often wheeze
- May be fever but no systemic signs of infection
- Wheeze but no signs of focal consolidation
- May cause acute exacerbations of COPD or asthma
47
Management of bronchitis?
- Usually none especially if viral
- Amoxicillin, doxycycline or clarithromycin- options if ill or chronic lung disease and purulent sputum
- Augmentin (smokers or COPD but not initial NICE recommendations for COPD)
- Manage exacerbation of COPD/asthma with steroids and increased inhalers
48
What is COPD?
- Airflow obstruction > FEV1/FVC ratio of <0.7
- Due to combination of:
1) Airway damage (bronchitis)
2) Parenchymal damage (emphysema)
- Damage is a result of chronic inflammation
49
Causes of COPD?
- Smoking
- Alpha-1-antitrypsin deficiency
- Air pollution/exposure to pollutants at work eg: Coal, cadmium, cotton, cement, grain
50
Why does alpha-1-antitrypsin defiency cause COPD?
- A1AT is a protease inhibitor
- Proteases are involved in structural changes and breakdown of lung tissue that results in emphysema
- A1AT is also inactivated by cigarette smoke - so smoking causes a similar effect to the deficiency
51
2 phenotypes of COPD?
- Blue bloaters
- Pink puffers
Most will be combination of both
52
What are blue bloaters?
- Predominantly chronic bronchitis (airway inflammation)
- Hypoventilation and cyanosis
- Cough
- Phlegm
- Cor pulmonale
- Resp failure
53
What are pink puffers?
- Predominantly emphysema
- Weight loss
- Breathlessness
- Maintained pO2
54
Main presentation of COPD?
- Cough: productive (clear/white thick sputum)
- Dyspnoea
- Wheeze
Smoker
Elderly
55
Clinical signs of COPD?
- Cyanosis
- Signs of CO2 retention - flap, confusion
- Barrel shaped, hyperinflated chest
- Raised JVP, ankle swelling, cor pulmonale
- Reduced chest expansion and air entry
56
What is Cor Pulmonale?
increased resistance in the blood vessels in the right side of the heart due to pulmonary hypertension/increased pulmonary resistance – causing symptoms of RHF
57
Investigations for ?COPD
- Post bronchodilator spirometry to show FEV1/FVC below 0.7
- CXR: Hyperinflation, bullae, flat hemidiaphragm
- FBC
- BMI
58
Management of COPD?
```
General:
- Smoking cessation
- Annual influenza vaccine
- One off pneumococcal vaccine
Bronchodilator therapy
- SABA or SAMA - 1st line
- Next step up is ?steroids
```
59
What features suggest COPD steroid responsiveness?
- Hx of asthma
- History of atopy
- Raised eosniphils
60
Treatment offered if they have steroid responsive features?
- ICS + LABA
| - If still breathless: triple therapy of ICS+LABA+LAMA
61
Treatment offered if they DONT have steroid responsive features?
- LABA and LAMA
62
Features and management of cor pulmonale?
```
Features:
- Peripheral oedema
- Raised JVP
- systolic parasternal haeve
- Loud P2
Management:
- Use a loop diuretic for oedema
- Consider LTOT
```
63
What can improve survival in stable COPD pts?
- Smoking cessation
- LTOT
- Lung volume reduction surgery
64
Who should be assessed for LTOT?
- Very severe airflow obstruction (FEV1 < 30% predicted
- Cyanosis
- Polycythaemia
- Peripheral oedema
- Raised jugular venous pressure (sign of cor pulmonale)
- Oxygen saturations <92 OA
65
How to assess for LTOT?
Measuring 2 ABGs on 2 occasions
At least 3 weeks apart
In patients with stable COPD on optimal management
66
Target O2 sats for COPD pt on oxygen therapy?
88-92%
67
Features of acute exacerbation of COPD?
- Increase in sx above and beyond normal day to day variation for 2 days
- Moderate needs tx
- Severe needs admission
- Associated with poor QoL and poor prognosis
68
Common infective organisms of AEofCOPD?
- haemophilus influenzae
- Streptococcus pneumoniae
- Moraxella catarrhalis
69
Management of AEofCOPD?
- Increase freq of bronchodilator use - consider nebs
- Give prednisolone 30mg daily for 7-14 days
- Oral abx only if clinical signs of pneumonia or purulent sputum
70
What is asthma?
A chronic inflammatory condition of the airways secondary to hypersensitivity
The symptoms are variable and recurring and manifest as reversible bronchospasm resulting in airway obstruction
71
3 pathological characteristic features of asthma?
- Airflow limitation
- Airway hyper-responsiveness to a range of stimuli
- Inflammation of the bronchi
72
Risk factors/causes of asthma?
- Persona/Fhx of atopy
- Antenatal: Maternal smoking and Viral infection during pregnancy
- Low birth weight
- Not being breastfed
- Maternal smoking around child
- Exposure to high conc of allergens (house dust mite etc)
- Air pollution
- Hygeine hypothesis - reduced exposure to infectious agents
73
What medication may patients with asthma be sensitive to?
Aspirin
74
2 phenotypes of asthma?
1) Eosinophillic:
- Non atopic
- Atopic - fungal allergy, pets, occupation, common aeroallergens
2) Non-eosinophillic
- Non smoking
- Smoking associated
- obesity related
75
What monoclonal antibody can be used to treat eosinophillic asthma?
- Anti-IgE > Omalizumab
76
Presentation of asthma?
- Cough - often worse at night or in morning
- Dyspnoea
- Wheeze
- Chest tightness
77
What triggers asthma symptoms?
- Allergens
- Infections
- Menstrual cycle
- Exercise
- Cold air
- Laughter/other emotions eg. stress, anger
78
Signs of asthma?
- Expiratory wheeze on auscultation
| - Reduced peak expiratory flow rate
79
RCP3 questions for assessing asthma severity?
- Recent waking in the night?
- Usual asthma symptoms in the day?
- Interference with ADLs?
80
Investigations for asthma?
Spirometry:
- FEV1
- FVC
- FEV1 significantly reduced, FVC normal, ratio <70%
- Bronchodilator reversibility test >12%
Fractional exhaled nitric oxide (FeNO)
CXR - rule out lung Ca in elderly/smokers
81
Step up management steps for asthma?
1) SABA
2) Not controlled on previous step OR newly-diagnosed with symptoms ≥ 3x week or night time waking – SABA and low-dose ICS
3) SABA + low-dose ICS + leukotriene receptor antagonist (LTRA)
4) SABA + low-dose ICS + LABA (+/- LTRA depending on response)
5) SABA +/- LTRA. Switch ICS/LABA for low dose ICS MART
6) SABA +/- LTRA + medium dose ICS MART, or consider changing back to a fixed-dose ICS and separate LABA
7) SABA +/- LTRA + one of the following:
- Increase ICS to high-dose only, as fixed regime not part of MART
- A trial of additional drug – e.g. LAMA or theophylline
- Seek advice from healthcare professional with expertise in asthma
82
What is maintenance and reliever therapy (MART)?
A form of combined ICS and LABA treatment
In which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required
83
Classifying acute asthma attack: MODERATE
- PEFR 50-75% best/predicted
- Speech normal
- RR <25/min
- Pulse <110bpm
84
Classifying acute asthma attack: SEVERE
- PEFR 33-50% best or predicted
- Cant complete sentences
- RR > 25/min
- Pulse >110bpm
85
Classifying acute asthma attack: LIFE-THREATENING
- PEFR <33% best or predicted
- Oxygen sats <92%
- Silent chest, cyanosis, or feeble resp effort
- Bradycardia, dysrhythmia or hypotension
- Exhaustion, confusion or coma
86
Escalatory steps to managing acute SEVERE asthma attack?
1) Oxygen
2) Salbutamol nebulisers
3) Ipratropium bromide nebulisers
4) Hydrocortisone IV OR Oral Prednisolone
5) Magnesium Sulphate IV
6) Aminophylline/IV salbutamol
87
Manageing mild-moderate asthma attack?
Beta 2 agonist via spacer (for a child < 3 years use close fitting mask)
1 puff every 30-60 seconds up to a maximum of 10 puffs
If symptoms are not controlled, repeat and refer to hospital
Give steroid for 3-5days.
88
What is bronchiectasis?
Permanent dilatation of the airways, secondary to chronic infection of inflammation
89
Causes of bronchiectasis?
- Post infective - TB, measles, pertussis, pneumonia
- Cystic fibrosis
- Bronchial obstruction - lung cancer, foreign body
- Immune deficiency - selective IgA, hypogammaglobulinaemia
- Allergic bronchopulmonary aspergillosis
- Ciliary dyskinetic syndromes (Kartageners, Youngs)
- Yellow nail syndrome ( Pleural effusion+Lymphoedema+Yellow nails)
- Post radiotherapy
- CTD
- IBD
- Post-transplant
90
What are features of Kartageners syndrome?
Aka Primary ciliary dyskinesia
Pathogenesis - dynein arm defect results in immotile cilia
Features:
- Dextrocardia or complete situs inversus
- Bronchiectais
- Recurrent sinusitis
- Subfertility (decreased sperm motility and defective ciliary action in fallopian tubes)
91
How does bronchiectasis come about?
- Microbial insult + defect in host response
- Leads to resp tract infection > bronchial inflammation > resp tract damage
- Leads to progressive lung disease
- Failure of mucociliary clearance and immune function
- Bronchitis > Bronchiectasis > Fibrosis
92
Most common infecting orgaisms isolated from bronchiectasis pts?
- Haem influenza (most common)
- Pseudomonas Aeruginosa
- Klebsiella spp.
- Streptococcus pneumonia
- Also: Moraxella cattarhalis, S. Aureus
93
Symptoms of bronchiectasis?
- Cough: Copious sputum, foul smelling, green/yellow, can be non-productive in 5%
- Recurrrent exacerbations w/ long recov time
- weight loss
- Dyspnoea
- Deterioration in control of prev stable lung condition
- Haemoptysis
- Chest pain
94
Signs of bronchiectasis?
- Finger clubbing
- Crepitations
- Bronchial breath sounds
- (rarely pyrexial)
95
What respiratory diseases cause clubbing?
```
ABCDEF
A - Abcess
B -Bronchiectasis
C - Cys Fibrosis
D - DONT say COPD
E - Empyeme
F - Fibrosis
```
96
What other diseases cause clubbing?
```
CLUBBING
C – Cyanotic heart disease
L – lung diseases
U – Ulcerative colitis + Crohn’s (IBD)
B – Biliary cirrhosis
B – Birth defects
I – infective endocarditis
N - Neoplasm (Lung Ca, mesothelioma)
G - I malabsorption (coeliac disease)
```
97
Investigations for bronchiectasis?
- Spirometry - obstructive pattern shown
- Sputum culture
- CXR
- High res CT scan (97%sens,99%spec)
- In younger pt w/ no smoking history do immunology, sweat test for CF and ciliary ix
- Bronchoscopy
98
Management of bronchiectasis
- Find and tx underlying cause: immune deficiency, CF etc
- Physical training
- Postural drainage
- Abx for exacerbations and long term if severe
- Bronchodilators
- Immunisations - flu+pneumococcal
- Surgery in selected cases - eg localised cases
99
What is respiratory failure?
Inadequate gas exchange by the respiratory system
Meaning that arterial oxygen dioxide or both cannot be kept at normal levels
Type 1 – hypoxia
Type 2 – hypoxia plus hypercapnia
100
What is difference between central and peripheral resp failure?
Central = Problem with brain/chemoreceptors
Peripheral = Problems with lungs/muscles
101
Causes of hypoventilation?
```
OHS (obesity hypoventilation system)
Hypothyroidism
Respiratory muscle weakness
Post-sedation
REM sleep
Loop diuretics causing metabolic alkalosis
```
102
Causes of hyperventilation?
```
Hyperthyroidism
Post cortical CVA (a stroke)
Liver cirrhosis
Metabolic acidosis
Anxiety and stress (common cause) overriding of normal drives by ‘emotional centres’, reticular activation centre and sympathetic nerves
```
103
What is Extrinsic Allergic Alveolitis?
AKA Hypersensitivity pneumonitis
- Condition caused by hypersensitivity induced lung damage due to a variety of inhaled organic particles
- Thought to be largely caused by immune-complex mediated tissue damage (type III hypersensitivity)
- Delayed hypersensitivity (type IV) thought to play a role
104
Examples of EAA?
- Bird fanciers' lung - avian proteins
- Farmers lung - spores of Saccharopolyspora rectivirgula
- Malt workers' lung - Aspergillus clavatus
- Mushroom workers' lung - thermophilic actinomycetes
105
How does EAA present?
- Can be acute (4-8hrs after exposure) or chronic
- SOB
- Dry cough
- Fever
106
Investigations for EAA?
- CXR: Upper/midzone fibrosis
- CT scan: May see 'ground glass' appearance ass w/ hypersensitivity
- Bronchoalveolar lavage - lymphocytosis
- Blood - no eosinophilia
107
What is occupational lung disease?
A response to inhaling some kind of trigger at work.
- Fume
- Dust
- Gas/Vapour
- Mist/Aerosol
108
By what mechanisms can occupational lung diseases occur?
- Direct injury: Acute irritant asthma, pulmonary oedema
- Infection: Silicotuberculosis
- Allergy: Asthma, EAA
- Chronic inflammation: COPD, bronchitis
- Destruction of lung tissue: Emphysema
- Lung or pleural fibrosis: Asbestos related disease
- Carcinogenesis: Lung cancer, mesothelioma
109
Effects of occupational lung disease?
- May be immediate or after a latent interval of months, years or decades
- Variable depending on indivudual susceptibility
- May occur whilst still at work or after retirement
- Effects range from mild to v severe
110
What is occupational asthma?
Definition in 90% of cases – asthma induced by allergy to an agent inhaled at work
Definition in 10% of cases – asthma induced by massive accidental irritant exposure at work (direct airway injury)
111
Occupations associated with occupational asthma?
- Farmers
- Bakers
- Factory workers
- Painters
112
Chemicals associated with occupational asthma?
- Isocyanates
- Platinum salts
- Soldering flux resin
- Flour
113
How does occupational asthma present?
- Pt concerned work worsening asthma
- Sx better at weekends/when away
- SOB
- Tachypnoea
- Cough
114
Investigations for occupational asthma?
- Serial PEF at work and away
- Spirometry
- Immunology
115
What is interstitial lung disease?
Disease of the alveolar/capillary interface
116
What are the 5 major groups of causes of interstitial lung disease?
1) Ass w/ systemic disease
2) Caused by environmental triggers
3) Granulomatous disease
4) Idiopathic
5) Other
117
Which systemic diseases can cause ILD?
- Any rheumatological contion: SLE, RA, seronegative spondyloarthropathies
- Vasculitis
- Vascular - AVMs
118
Which environmental triggers can cause ILD?
- Drugs
- Fungal
- Dusts
119
Which granulomatous diseases can cause ILD?
- Sarcoidosis
| - Wegeners
120
What are the main idiopathic causes of ILD?
1) IPF (idiopathic pulmonary fibrosis)
2) NSIP (non-specific interstitial pneumonia)
3) DIP (desquamative interstitial pneumonia)
4) COP (cryptogenic organising pneumonia)
121
What are the other main causes of ILD?
LAM – lymphaniolyomyomatosis
- ‘Benign’ proliferation of lymphatic smooth muscle cells
- Leads to lung cysts, respiratory failure, pneumothorax, chylous pleural effusion
- Often presents in pregnancy – hormonal influences
- Treated with hormonal manipulation – rapamycin, transplant
Eoisinophilic pneumonia
122
What diseases causing ILD predominantly affect upper zones of lungs?
```
C – Coal worker’s pneumoconiosis
H – Histiocytosis/ hypersensitivity pneumonitis (EAA)
A – Ankylosing spondylitis
R – Radiation
T – Tuberculosis
S – Sarcoidosis/ silicosis
```
123
What diseases causing ILD predominantly affect lower zones of lungs?
- Idiopathic pulmonary fibrosis
- Most CTD
- Drug induced - amiodarone, bleomycin, methotrexate
- Asbestosis
124
Symptoms of ILD?
- Cough
- SOB
- Constitutional symptoms
PMH of lung problems
Drugs, occupation, pets, smoking
125
Signs of ILD?
- Clubbing
- Fine end inspiratory crepitations
- Skin, eye, joint sx
126
Investigations for OLD?
- CXR
- Pulm function tests - restrictive pattern, reduced gas transfer, low/normal PaO2
- Blood tests
- High res CT
- Broncho-alveolar lavage
127
Treatment of ILD?
- manage underlying cause
| - May response to steroids
128
What is idiopathic pulmonary fibrosis?
Chronic lung condition characterised by progressive fibrosis of the interstitium of the lungs.
50-70yrs. 2x more common in men.
129
Risk factors for IPF?
- Smoking
- Infectious agents: CMV, Hep C, EBV
- Dust exposure (metals, woods)
- Antidepressants (imipramine)
- Chronic aspiration
- Genetics
130
Features of IPF?
- Progressive exertional dyspnoea
- Bibasal crackles on auscultation
- Dry cough
- Clubbing
131
Investigations for IPF?
- Spirometry: Restrictive disease (normal/decreased FEV1, decreased FVC, normal/increased FEV1/FVC ratio)
- Transfer factor (TLCO): reduced due to imparied gas exchange
- Imagine
- Bilateral intersitial shadowing
- Honeycombing/ground glass appearance
- ANA and RhF
132
How is IPF managed?
- Pulm rehab
- Pirfenidone (antifibrotic)
- Supportive: O2, transplant, GORD, Cough,
133
Treatment of acute exacerbations of IPF?
- Broad spec abx (tazocin often)
- Steroids
- Oxygen
- ?Ventilator
134
What is sarcoidosis?
- Multisystem disorder of unknown aetiology
- Characterised by non-caseating granulomas
- More common in young adults
- More common in people of african descent
- Predominantly lymph nodes and lungs
135
How does sarcoidosis present?
- Can be asymptomatic in 50%
- Non specific constitutional symptoms: fever, fatigue, cachexia, lack of energy
- Specific features by body systems
136
Chest features of sarcoidosis?
Symptoms: Cough, breathlessness, wheeze
Signs: Wheeze, fine crackles, bilateral hilar lymphadenopathy
137
Skin features of sarcoidosis
- Erythema nodosum: Big blotchy tender lumps affecting mainly shins
- Waxy maculopapular lesions
- Lupus pernio
- Scars on skin: due to granuloma infiltration
138
Eye manifestations of sarcoidosis?
- Anterior uveitis
- Posterior uveitis
- Conjunctival nodes
- Lacrimal gland enlargement
- Heefordts syndrome
139
What is Heerfordts syndrome?
- Parotid gland enlargement
- Facial palsy
- Anterior uveitis
- Fever
140
Bone manifestations of sarcoidosis?
- Arthralgia
| - Bone cysts
141
Metabolic features of sarcoidosis?
- Hypercalcaemia
142
Liver manifestations of sarcoidosis?
- Granulomatous hepatitis
| - Hepatosplenomegaly
143
What are the neurological manifestations of sarcoidosis?
- Meningeal inflammation
- Seizures
- Mass lesions: Granulomata
- Hypothalamic pituitary infiltration
- Mononeuropathy
144
Cardiac manifestations of sarcoidosis?
- RARE
- Ventricular arrhytmias
- Condcution defects
- Cardiomyopathy w/ cardiac failure
145
Syndromes associaed with sarcoidosis?
Lofgren’s syndrome - an acute form of the disease characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis
Mikulicz syndrome - enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma
Heerfordt’s syndrome – parotid enlargement, fever and uveitis
146
Diagnosis of sarcoidosis?
- Clin features
- Radiology
- Biopsy
147
What will be raised in sarcoidosis?
- Serum ACE
| - Calcium
148
Management of sarcoidosis?
- Steroids
- Start with oral prednisolone
- Wean off when can.
149
What is Langerhans cell histiocytosis?
- Rare condition associated with abnormal proliferation of histiocytes
- Typically presents in childhood with bony lesions
- Granulomatous disease
150
Features of LCH?
- Bone pain – typically in the skull or proximal femur
- Well-defined ‘punched out’ osteolytic lesions seen on skull
- Cutaneous nodules
- Recurrent otitis media/mastoiditis
- Tennis racket shaped Birbeck granules on electromicroscopy
Pulmonary LCH – isolated smoking related disease, probably different aetiology
151
What is acute respiratory distress syndrome?
ARDS aka Acute lung injury
- May be caused by direct lung injury or occur secondary to severe systemic illness
- Lung damage and release of inflammatory mediators cause increased capillary permeability and non-cardiogenic pulmonary oedema
- Often accompanied by multiorgan failure
- Mortality of 40%
- Significant morbidity in those who do survive
152
Pulmonary causes of ARDS?
- Pneumonia
- Gastric aspiration
- Inhalation of damaging agent eg. smoke, poison
- Injury
- Vasculitis
- Contusion
153
Other causes of ARDS?
- Obstetric events (eclampsia, amniotic fluid embolus)
- Drugs/toxins (aspirin, heroin)
- Shock
- Septicaemia
- Haemorrhage
- Multiple transfusions
- DIC
- Pancreatitis
- Acute liver failure
- Head injury
- Trauma
- Malaria
- Burns
- Fat embolism
154
Clinical features of ARDS?
- Acute onset
- Severe symptoms
- Dyspnoea
- Tachypnoea
- Tachycardia
- Bilateral lung crackles
- Cyanosis
- Peripheral vasodilation
155
ARDS investigations?
- Bloods: FBC, U&E, LFT, clotting
- Amylase: Pancreatitis is a cause
- Blood cultures
- ABG - low paO2
- CXR: bilateral pulm infiltrates
- Pulmonary artery catheter
156
Diagnostic criteria for ards?
1) Acute onset - within 1 week of known risk factor
2) Pulmonary oedema - bilateral infiltrates on CXR, not fully explained by effusions, lobar/lung collapse or nodules
3) Non-cardiogenic
4) Hypoxaemia - pO2/FiO2 <40kPa
157
Management of ARDS?
- Admit to ITU
- Oxygenation/ventilation to treat hypoxaemia
- Tx of underlying cause
- Nutritional support: Enteral, high fat antioxidant forumulations
- Prone positioning and muscle relaxants
158
What is mesothelioma?
- Cancer of the pleura
- Commonly associated with asbestos exposure
- Rarely metastasises
- Long latency
- Rapidly progressive and incurable pleural effusion
- Progressive breathlessness, chest pain, weight loss
- Average survival 8-14months
159
Causes of mesothelioma?
- Exposure to asbestos
- Blue asbestos (crocidolite) is most dangerous
- Long latent period after exposure 30-40yrs
- More common on men by 3x
160
How does mesothelioma present?
- Progressive shortness of breath
- Chest pain
- Pleural effusion
- Constitutional symptoms: W loss, fever, night sweats, lymphadenopathy
- Abdo bain, palpable chest masses
- SVCO
- Presents like any lung cancer
161
Which other tumours can affect pleura?
Malignant: Mesothelioma, Primary lymphoma, Pleural Thymoma, Pleura sarcoma
Benign: Fibrous
162
How is mesothelioma investigated?
- CXR
- High res CT scan
- Pleural fluid aspiration - straw or blood stained
- Pleural biopsy for histology
163
Management of mesothelioma?
- Palliative chemotherapy
- May be surgical and radiotherapy role
- Financial compensation for diagnosis
- Median survival 8-14months
164
What is TB?
An infective disease which can be pulmonary or extra-pulmonary.
Caused by Mycobacterium Tuberculosis or Mycobacterium Bovis.
165
What are mycobacteria?
Aerobic, non-spore forming, non-motile bacteria with high content of high molecular weight lipids in its cell wall
Slow growing – takes 15-20 hours to double, so takes 3-8 weeks to grow on solid media
166
Risk factors for TB?
- Foreign born (eg Sub-saharan Africa)
- HIV+ve
- IVDU
- Homeless
- Alcoholic
- Prisons
167
How does TB spread?
- Spread in aerosol droplets
168
What is primary TB?
- A non-immune host who is exposed to M. tuberculosis may develop primary infection of the lungs
- A small lung lesion known as a Ghon focus develops, of tubercle-laden macrophages
- The combination of a Ghon focus and hilar lymph nodes is known as a Ghon complex
- In immunocompetent people the lesion initially usually heals by fibrosis.
- Those who are immunocompromised may develop disseminated disease (miliary tuberculosis).
169
What is secondary TB?
- If the host becomes immunocompromised the initial infection may become reactivated
- Reactivation generally occurs in the apex of the lungs and may spread locally or to more distant sites
- Possible causes of immunocompromise include:
Immunosuppressive drugs including steroids
HIV
malnutrition
170
Where else other than lungs can secondary TB occur?
- Central nervous system (tuberculous meningitis - the most serious complication)
- Vertebral bodies (Pott's disease)
- Cervical lymph nodes (scrofuloderma)
- Renal
- Gastrointestinal tract
- GU tract
- Bones and joints
- Pericarditis
171
Clinical features of TB?
- Weight loss and night sweats
- Low grade fever
- Anorexia
- Malaise
- Cough >3weeks
- Maybe haemoptysis
172
Symptoms specific to primary TB disease?
- Chest pain and dyspnoea
- Upper lobe consolidation - dull apex with bronchial breathing
- Compression by LN causing collapse, cough etc
- Features of cell mediated immunity
173
Possible features of secondary TB?
- Asymptomatic, presenting as nodules, fibrosis or cavity on CXR
- Systemic presentation
- Haemoptysis
- Pneumonic presentation
- Pleurisy
174
Extra-pulmonary TB features?
Systemic features: Weight loss, low grade fever, anorexia, night sweats, malaise
Lymph node TB: Swelling +/- discharge
Bone TB: Painful/swollen joints, Potts disease
Abdo TB: Ascities, abdominal lymph nodes, sx of malabsorption
GU TB: Epididymitis, urinary freq, dysuria, haematuria
TB Meningitis: Normal meningtis sx, CSF sample +++ glucose and protein
175
How is TB diagnosed?
- Ziehl Neelsen stain for AFB
176
What culture medium is needed and how long to grow?
Solid media: Lowenstein-Jensen or Middlebook 7H12 agar. 3-8weeks.
Liquid media: Middlebook 7H12. 1-3weeks.
177
X-ray features of TB?
1 - consolidation
2 - cavitation
3 - calcification
4 - pleural effusion
178
Treatment of active TB?
RIFAMPICIN 6/12
ISONIAZID 6/12
PYRAZINAMIDE 2/12
ETHAMBUTOL 2/12
179
Treatment of latent TB?
3 months of Isoniazid and Rifampicin
Give Pyridoxine to prevent peripheral neuropathy.
180
Side effects of rifampicin?
- Stains body secretions/urine orange
- Induces liver enzymes
- Flu like sx
181
Side effects of isoniazid?
- Polyneuropathy (prevent by giving Pyridoxine)
- Hepatitis
- Haemolytic anaemia
182
Side effects of pyrazinamide?
- Hepatitis
- Hyperuricaemia and gout
- Rash and arthralgia
183
Side effects of ethambutol?
- Optic neuritis
184
How to screen for TB?
- Mantoux test
| - Interferon gamma blood test
185
What is pulmonary hypertension?
Resting mean pulmonary artery pressure of >25mmHg
Can be primary (PAH) or secondary
186
What is PAH?
Diagnosed when there is raised resting pulmonary artery pressure in the absence of underlying chronic lung disease
187
What diseases may pulmonary hypertension occur secondary to?
- Left heart disease: Valvular, systolic dysfunction, diastolic dysfunction
- Lung disease and/or hypoxia: COPD, obstructive sleep apnoea, lung fibrosis
- Thromboembolic occlusion of proximal or distal pulmonary vasculature
- Multifactorial: Myeloproliferative disorders, sarcoidosis, glycogen storage disease
188
What are the causes of PAH?
- Hereditary – 10% cases inherited in AD fashion
- Idiopathic (no cause identified)
- Inflammatory conditions - Systemic sclerosis, systemic lupus erythematosus, rheumatoid arthritis
- Recreational drugs - long term use of cocaine and amphetamines
- Anorexigenic drugs – (suppress appetite) – fenfluramine
- HIV infection
- Portal hypertension (portopulmonary hypertension)
- Congenital heart disease with systemic to pulmonary communication (atrial septal defect ventricular septal defect)
- Schistosomiasis
- Chronic haemolytic anaemia
- Pulmonary veno-occlusive disease
189
What protein plays a role in PAH?
Endothelin
190
How does PAH present?
- Classically: Progressive exertional dyspnoea
- Plus lethargy and fatigue
- Other possible symptoms: Exertional syncope, exertional chest pain, peripheral oedema, weakness, abdo pain
191
Signs on exam of PAH?
- Oedema
- Cyanosis
- Right ventricular heave
- Loud P2
- Raised JVP with prominent a waves
- Tricuspid regurgitation
192
Investigations of PAH?
- Aim is to confirm presence of pulm htn and show cause
- CXR: Enlarged proximal pulmonary arteries
- ECG: RVH and P pulmonale
- ECHO: RV dilatation and/or hypertrophy
- TFTs to rule out hypothyroid
- Autoimmune screening
- Routine biochemistry
193
How is P-pulmonale seen on ECG?
Right atrial enlargement.
| Seen as tall, peaked P wave on ECG.
194
Management of PAH?
- Tx of underlying cause
- Oxygen
- Anticoagulation
- Following this: Acute vasodilator therapy
195
What are the features of Wegeners/GPA?
- High incidence of upper airways involvement (nasal crusting, destruction)
- Endobronchial involvement
- Cavitating nodules
- C-ANA, anti-PR3+ve
- See MSK
196
Features of churg-strauss?
- High incidence of upper airway involvement (polyps, sinusitis)
- V high incidence of preceding asthma
- Ground glass, consolidation, bronchial wall thickening
- Peripheral eosinophilia
- P-ANCA, anti-MPO +ve
197
Features of Goodpastures syndrome?
- Antibodies form to basement membrane (type 4 collagen)
- Largely affects the kidneys and the lungs because basement membranes are very important in these organs
- Presents with cough, haemoptysis, and tiredness followed by acute glomerulonephritis
- Can cause intrapulmonary haemorrhage so can produce diffuse infiltrates on the CXR
- Treatment – corticosteroids (to suppress the immune system)
198
How to classify pleural effusions?
Transudative (<30g/L protein)
- Often caused by organ failure (esp. renal failure/nephrotic syndrome)
Exudative (>30g/L protein)
- Anything that affects the structure or causes increased permeability of membranes. Inflammation and CTD disorders.
199
Causes of transudative pleural effusion?
- Heart failure
- Hypoalbuminaemia (liver disease, nephrotic, malabsorption)
- Hypothyroidism
- Meigs syndrome
- Renal failure
- Nephrotic syndrome
- Liver cirrhosis
200
Causes of exudative pleural effusion?
- Infection: pneumonia (most common), TB, subphrenic abcess
- Autoimmune/Inflam/CTD: RA, SLE
- Neoplasia: Lung cancer, mesothelioma, metastases from other sites
- Pancreatitis
- Pulm embolism
- Dresslers syndrome
- Yellow nail syndrome
- Traumatic: haemothorax, chylothorax
201
Presenting symptoms of pleural effusion?
- Dyspnoea
- Cough - non-productive
- Chest pain
- Weight loss
202
Signs of pleural effusion?
- Dullness too percussion
- Reduced breath sounds
- Reduced chest expansion
- Reduced tactile vocal fremitus
203
Investigating pleural effusion?
- PA CXR in all pt
- USS- to visualise and aspirate
- Contrast CT
- Pleural aspiration
204
What do you test pleural fluid for?
- pH
- Protein
- LDH
- Cytology
- Microbiology
205
What criteria is used to differentiate between transudative or exudative effusion?
LIGHTS criteria.
Exudate likely if one of following met:
- Pleural fluid protein/serum protein >0.5
- Pleural fluid LDH/serum LDH >0.6
- Pleural fluid LDH >2/3 the upper limits of normal serum LDH
206
What may low glucose in pleural fluid aspiration point to?
RA
| TB
207
What may raised amylase in pleural fluid point to?
Pancereatitis
| Oesophageal perforation
208
What may heavy blood staining mean in pleural fluid?
mesothelioma
pulm embolsim
TB
209
Treatment of pulmonary effusions?
- Simple: observe and follow up
- If complicated/empyema: Drainage, fibrinolytics, surgery
- Tx of underlying cause
- Drain exudates
- Transudate resolve if cause resolved
210
When is a chest drain indicated for pleural effusion?
- Malignant and symptomatic
- empyema/complicated parapneumonia
- traumatic haemothorax
- Post-op
- Ventilated pt
- Site
211
How to manage recurrent pleural effusions?
- Recurrent aspiration
- Pleurodesis
- Indwelling pleural catheter
- Drug management for sx
212
What is pleural infection?
All patients with a pleural effusion in association with sepsis or a pneumonic illness require diagnostic pleural fluid sampling
if the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage
if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed
213
Whaat is a pneumothorax?
- Air in the pleural space
- Leading to partial or complete collapse of the lung
- Occurs spontanenously or 2ndary to chest trauma
- A 'tension pneumothorax' is rare unless pt on NIV or a ventilator
- In this situation (tension pneumo) the pleural tear acts as a one-way valve through which air passes during inspiration but is unable to exit on expiration. The lung will then flatten because the pressure in the pleural space is greater than the pressure inside the lung
214
Causes of pneumothorax?
Traumatic: Penetrating injuries, eg stab, RTA, rib fractures
Spontaneous:
- Primary (incl. Marfans) - Primary spontaneous pneumothorax
- Secondary - COPD, pulm fibrosis
- Infections - pneumocystis pneumonia, TB
- Catamenial - w/ menstruation
Iatrogenic: pacemakers, central lines, ventilation
215
Who gets affected by pneumothorax?
- Men 6x more than women
| - Often pt tall and thin
216
Clinical presentation of pneumothorax?
- Sudden onset of unilateral pleuritic chest pain
| - Breathlessness
217
Signs of pneumothorax?
- Reduced breath sounds
- Hyper resonant percussion on exam
- Pallor
- Tachycardia
- Tachypnoea
- Sweating
- Reduced chest expansion on side of lesion
- Low o2
- low BP
218
How to dx pneumothorax?
- Hx and exam and signs
- Chest XR - see air in pleural cavity
- Tension pneumothorax = clin diagnosis
219
Treatment of tension pneumothorax?
- NEedle decompression and chest tube insertion
220
What is a bronchial carcinoma?
- Malignant neoplasm of lung arising from epithelium of bronchus or bronchiole
- Accounts for 95% of primary lung tumours
- 3:1 male to female
221
Classifications of lung cancer>
SCLC - 15% of cases, worse prognosis
NSCLC
- Squamous, adenocarcinoma, large cell, alveolar cell, bronchial adenoma
222
Causes of lung cancer?
Smoking = most common cause
Higher incidence in urban than rural areas
Passive smoking
Environmental – radon exposure, asbestos, polycyclic aromatic hydrocarbons and ionising radiation
Occupational – arsenic, chromium, nickel, petroleum products and oils
Host factors – pre-existing lung disease e.g. PF, HIV infection, Genetic factors
223
Characteristics of squamous cell cancer?
- Most present as obstructive lesion leading to infection
- Occasionally cavitates
- Local spread is common
- Widespread metastases occur late
- Typically central
- Associated with parathyroid hormone-related protein (PTHrP) secretion hypercalcaemia
- Strongly associated with finger clubbing
- Hypertrophic pulmonary otseoarthropathy (HPOA)
224
Features of large cell lung cancer?
- Metastasize early
- Typically peripheral
- Anaplastic, poorly differentiated tumours with a poor prognosis
- May secrete beta-HCG
225
Features of adenocarcinoma of lung?
- Most common lung cancer associated with asbestos exposure, although the majority of patients who develop lung adenocarcinoma are smokers
- Proportionately more common in non-smokers
- Usually occurs peripherally
- Local and distance metastases
226
Features of small cell lung cancer?
- Usually central
- Arise from APUD cells:
- Amine – high amine content
- Precursor uptake – high uptake of amine precursors
- Decarboxylase – high content of the enzyme decarboxylase
- Association with ectopic ADH and ACTH secretion
- ADH – hyponatraemia
- ACTH – Cushing’s syndrome
- ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis
- Lambert-Eaton syndrome – antibodies to voltage gated calcium channels causing myasthenic like syndrome
227
Management of small cell lung cancers?
Usually metastatic disease by time of diagnosis (much poorer prognosis than non-small cell)
Patients with very early stage disease (T1-2a, N0, M0) are now considered for surgery.
However, most patients with limited disease receive a combination of chemotherapy and radiotherapy
Patients with more extensive disease are offered palliative chemotherapy
228
4 main ways in which lung cancers can present?
1) Local effects of a tumour within a bronchus
2) Spread within the chest
3) Metastatic disease
4) Non-metastatic manifestations
229
Clinical features of lung cancer, due to local effects?
- Cough
- Chest pain
- haemoptysis
- Breathlessness
- Dysphagia
- Wheeze
- Hoarse voice
- Recurrent infections
230
Effects of lung cancer spreading to chest?
Pancoast’s tumour - Spread to involve the brachial plexus causes pain in the shoulder and inner arm (shoulder pain, parasthesia)
Horner’s syndrome – Spread to the sympathetic ganglion (HS marked by a contracted pupil, drooping upper eyelid, inability to sweat on the side of face where the damage is)
Hoarseness and a “bovine cough” – bovine cough = where they sound like there hooting/blowing air out without being able to make the proper rumbling cough sound. This is caused by spread to the recurrent laryngeal nerve.
Involvement of the oesophagus, heart or SVC – causes upper limb oedema, facial congestion and distended neck veins (increased JVP)
231
Where do lung cancer metastise to?
- LN
- Bone
- Brain
- Liver
- Adrenal glands
232
Investigating lung cancer?
CXR
CT
Bronchoscopy
PET scanning
233
Management of nsclc?
- MDT approach to care
- Surgery can be curative – around 20% suitable for surgery
- Mediastinoscopy performed prior to surgery as CT does not always show mediastinal lymph node involvement
- Radiotherapy – curative or palliative
- Poor response to chemotherapy – given in advanced disease, improves median survival from 6 to 10 months
234
What cancers spread to lung?
```
Breast
colorectal
prostate
kidney - RENAL CELL CARCINOMA is most common to present as pulm mets.
melanoma
thyroid
lymphoma
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