respiratory Flashcards
define asthma:
common chronic inflammatory disorder of the airways characterised by reversible airflow limitation, airway hyperresponsiveness and bronchi inflammation
what is atopy?
genetic predisposition to IgE-mediated allergen sensitivity
atopic triad includes:
asthma
rhinitis
dermititis
what is the hygiene hypothesis?
epidemiology shows increased autoimmune and allergic responses in developed countries
reduced exposure to infectious pathogens at an early age predisposes individuals to such diseases
encourages Th2 predominant response ->IgE
patients with aspirin induced asthma commonly exhibit Samter’s triad, what is this?
asthma
aspirin sensitivity
nasal polyps
how are the different types of sensitisers of occupational induced asthma categorized?
low molecular weight
high molecular weight
how do low molecular weight compounds trigger asthma in occupational setting:
produce IgE mediated hypersensitivity response
the effects are immediate/soon after exposure
examples of low molecular weight triggers of asthma:
flour
latex
how do high molecular weight compounds trigger occupational asthma:
compounds develop a complex immune response after long term repeated exposure to the compound
examples of high molecular weight compounds which trigger asthma:
wood dust, isocyanates
what is the key to dx occupational asthma:
peak flow diaries used during periods of work and holiday
refer to specialist
what exposures contribute to exercise induced asthma:
cold air exposure
environmental pollutants
what is the pathophysiology of the early phase of asthma:
inhalation of allergens -> T1 hypersensitivity reaction immediately
sensitisation occurs during allergen exposure -> release of IgE Abs from plasma cells, which bind to mast cell receptors
subsequent exposure -> degranulation of mast cells and histamine release
->sm contraction, bronchoconstriction
inflammation -> airway obstruction
what is the pathophysiology of the late phase of asthma:
the initial early phase followed by:
recruitment of variety of inflammatory cells hours later (PMN cells, T cells)
more complex than early phase
B-agonists do not cause complete reversal
what is the pathophysiology of the chronicity of asthma:
response to persistent chronic inflammation
airways lay down fibrous tissue
remodeling occurs -> fixed airway obstruction, narrowing irreversible
what are the typical clinical features of asthma:
fine between attacks
sob, exp wheeze, cough
worse at night
what other signs of asthma may be present:
prolonged exp phase
tachypnoea
Harrison’s sulcus
what is a Harrison’s sulcus?
groove at inferior border of the ribcage seen in children with chronic severe asthma
also rickets
what are the clinical features of a severe asthma attack (acute)?
confused mental status
resp effort decreased
hypoxia
how is diagnosis of asthma investigated?
spirometry and PEFR
FVC?
forced vital capacity - exp
max exp following full insp
FEV1?
forced expiratory volume in 1 sec
what spirometry changes seen in obstructive picture?
FVC: N or reduced due to air trapping in bases
FEV1: reduced
REV1/FVC ratio: <70%
what is indicative of asthma on spirometry:
reversibility when bronchodilators used
12%
how does asthma look on PEFR:
variability
step-wise mx of chronic asthma in children:
1. SABA \+ v. low dose ICS or LTRA if <5 \+LABA or LTRA if <5 \+Low dose ICS or LTRA \+med dose ICS or theophylline \+ oral pred, refer
step-wise mx of chronic asthma in adults:
1. SABA \+ICS \+LTRA \+LABA \+increase ICS + LAMA/LTRA/theophylline \+increase ICS +LAMA/LTRA/theophylline+B-ag tablet \+Oral pred, refer
when should you step up from just SABA tx?
if using saba >3x per week
acute mx of asthma attack?
- Salbutamol, ipratropium nebs, o2 sats>94, steroids
- IV Mg sulfate
- IV amiophylline, B2 Agonist infusion
identifying life threatening asthma attack in children:
silent chest, cyanosis, exhaustion, confusion, poor effort
<92% sats
PEFR<33% predicted for age
identifying life threatening asthma attack in adults:
silent chest, cyanosis, echaustion, CONFUSION poor effort
<92% sats
PaO2<8kPa on ABG
PEFR <33% expected
(also acidosis on ABG indicating CO2 retention)
what is Churg-Strauss sydrome?
vasculitis affecting the small, medium sized vessels
characterised by late onset asthma, rhinitis, paranasal sinusitis, pulmonary infiltrates
3 phases of Churg-Strauss syndrome?
- allergic - rhinitis, asthma
- eosinophillic - infiltrative disease ->lung/intestine
- vasculitic - systemic vasculitis, granulomatous infiltration (renal failure, petechial rash)
65yom presents to GP dyspnoea, wheeze, non-productive cough
no hx atopy
also has low grade fever, malaise, weight loss
raised IgE, CRP, positive p-ANCA?
churg-strauss
moa of ipratropium bromide?
short acting muscarinic antagonist
moa amiophylline?
phosphodiesterase-Inhibitor
MOA adrenaline?
alpha-agonist
which antibodies involved in T1 hypersensitivity reaction?
IgE
which antibodies involved in T2 hypersensitivity reaction?
IgM, IgG
cytotoxic
how is normal airway flow described?
laminar flow - ordered flow, quicker in the centre
as the airway divides and becomes narrower, what happens to the air flow?
becomes turbulent flow
what is the condition for Pouseuille’s law to apply?
laminar flow
what is Pouseuille’s law?
Resistance=8xLengthxviscosity/π x radius^4
according to Pouseuille’s law, what happens to the resistance when the radius doubles?
airway resistance decreases by 16x
what does bronchomotor tone control?
ease with which air is conducted through the airways
what is the rhythm of bronchomotor tone?
follows a circadium rhythm - higher in the mornings inhaled stimuli (smoke) can increase tone
how do bronchodilators act and what conditions do they treat?
they act to reduce the bronchomotor tone
relieve symptoms in COPD and asthma
3 classes of bronchodilator drugs?
Beta-2 agonists
muscarinic antagonists
methylxanthines
how many times does the G-coupled protein receptor pass through the cell membrane and what is this called?
7 times
7 transmembrane domain
G-coupled protein receptors are metabotropic receptors - what does this mean?
their actions are mediated by a secondary messenger (cAMP, DAG)
where are B-2 adrenoreceptors found and which nervous system is affected?
primarily the lungs - bronchial smooth muscle
sympathetic
how do B2 agonists work?
activate B2 adrenoreceptors in the broncial smooth muscle by the sympathetic NS and cause bronchodilation through smooth muscle relaxation
what are the additional beneficial effects of B2 agonists IN the LUNGS?
reduce release of inflammatory mediators from mast cells
increased mucociliary clearance
examples of short and long acting B2 agonists?
what makes them short/ling acting?
saba - Salbutamol - hydrophilic - <5mins
laba - salmetarol - lipophilic - 12hrs
what are the adverse effects of B2 agonists?
tachycardia - B1/2 adrenoreceptors - heart
arrhythmias - “
tremor - B2 adrenoreceptors skeletal muscle
hypokalaemia - B2 adrenoreceptors Na/K-ATPase channels
what type of receptors are muscarinic receptors?
which nervous system activates them?
cholinergic (related to ACh)
metabotropic G-protein coupled receptors
parasympathetic NS
how many subtypes of muscarinic receptor are there and what are the most important ones for bronchodilation?
5
M3 (also M1)
how do muscarinic antagonists work?
block action of muscarinic ACh receptors - non-selective
relax the smooth muscle in the airways
examples of short and long acting muscarinic antagonists?
short - ipratropium
long - tiotropium
adverse effects of muscarinic antagonists?
dry mouth - xerostomia
urinary retention
headache
pupillary dilation - exacerbation of glaucoma
what are methylxanthines?
nonselective phosphodiesterase inhibitors
cause bronchodilation among other effects
2 examples of methylxanthines?
theophylline
amiophylline (IV)
MOA of mexylxanthines?
adenosine receptor antagonists
name 4 various effects of methylxanthines?
immunomodulation
anti-inflammatory
vasodilation
bronchodilation
what needs to be measured with methylxanthines?
toxicity - narrow therapeutic window - 1-1.5
what does methylxanthine toxicity look like:
met - hypokalaemia, hyperglycaemia CV - hypotension, tachycardia, tachyarrhythmias GI - n/v/d neuro - mood changes, insomnia, seizures muscle - coarse tremor, rhabdo
advantages of inhaler devices?
accurate target of site of action
reduced therapeutic doses
reduced systemic consequences
reduced sfx
disadvantages of inhaler devices?
patient education needed
compliance variable-poor
4 types of inhaler device for delivering bronchodilators?
MDI - metered-dose inhalers
BAI - breath actuated inhalers
volume spacer
nebuliser - vapourises liquids
define COPD:
progressive obstructive airway disease, non-reversible
what does COPD incorporate?
disease from airways and parenchyma in the forms of chronic bronchitis and emphysema
aetiology of COPD?
smoking most commonly (90%smoking related)
Alpha1-antitrypsin deficiency
what type of emphysema commonly seen in copd?
centriacinar (as opposed to panlobular)
what is the inheritance of alpha-1-antitrypsin deficiency and how is it implicated in copd?
autosomal codominant
protease inhibitor - acts in lung parenchyma to oppose action of elastase (which breaks down elastin - important for alveoli function) - leads to emphysema
what type of emphysema commonly seen in alpha1antitrypsin deficiency?
panlobular with lower zone predominance
higher risk of HCC
pathophysiology of copd generally?
disease of both airways and alveoli
what is the pathophysiology of copd in the airways specifically?
chronic bronchitis - inflammation of bronchi - goblet cell hyperplasia mucus hypersecretion chronic inflammation and fibrosis narrowing of small airways
how is chronic bronchitis defined?
chronic productive cough for 3+ months on 2 consecutive years where other causes excluded
pathophysiology of copd in alveoli specifically?
Inflammatory processes lead to the production of proteases by inflammatory cells such as macrophages. Elastase breaks down elastin, important to the structural integrity of the alveoli.
leads to alveolar collapse, dilation and bullae formation
what is bullae formation?
alveoli dilate and join with neighboring alveoli forming bullae
definition of emphysema?
permanent enlargement of airspaces distal to the terminal bronchiole when interstitial pneumonias are excluded
what is cor pulmonale?
right ventricular HF in response to pulmonary disease
clinical features of copd?
cough and dyspnoea hallmarks
also productive cough - white
orthopnoea
signs indicating copd?
dyspnoea pursed lip breathing use of accessory muscles wheeze coarse crackles loss of cardiac dullness downward displacement of liver
what are signs of co2 retention:
drowsy
asterixis
confusion
why does pursed lip breathing help in copd?
prevents alveolar collapse by increasing positive end expiratory pressure
signs of cor pulmonale?
peripheral oedema
left parasternal heave (right ventricular hypertrophy)
raised JVP
hepatomegaly
what scale is used for categorizing copd?
MRC dyspnoea scale (1-N, 5-severe at rest)
what is an acute exacerbation of copd?
sustaining worsening of sx that may interrupt patient’s stable course
infective or non-infective
how is the diagnosis and severity of copd best investigated?
spirometry - assesses airway obstruction
what will spirometry show in copd?
FVC: N or reduced due to air trapping
FEV1: reduced greatly
FEV1:FVC: <70%
how do NICE guidelines stage COPD severity?
based on FEV1 as a % of predicted for age
3= FEV1<50%
4=<30%
bedside ix for copd?
obs BMI sputum culture if purulent pulse ox ABG - hypoxia/hypercapnia ECG - cor pulmonale
what may bloods show in COPD?
anaemia, polycythaemia on FBC
what will a CXR show in COPD?
hyperexpanded
flattened hemidiaphragms
hypodense
saber-sheath trachea
mx of COPD:
B2 agonists and Muscarinic antagonists relieve sx
LTOT and smoking cessation decrease mortality
medical mx of copd:
- SABA/SAMA
2 (FEV1>50) regular LAMA or LABA
2 (FEV1<50) regular LAMA or LABA+ICS - regular LABA + LAMA + ICS
who is LTOT reserved for in copd?
when stable have pa02<7.3 (x2) or pa02<8 + pulmonary HTN peripheral oedema nocturnal hypoxaemia secondary polycythaemia
how long is LTOT needed for per day?
15 hours
what other complimentary therapies can help copd mx?
annual flu and one off pneumococcal vaccine
PT
how to treat an acute exacerbation of copd?
bronchodilators
pred 30mg for 7-14 days
Abx - tetracyclines (doxy)
which type of respiratory failure are copd patients at risk of getting?
T2 hypercapnic
what does T2RF look like on ABG?
PaO2<8kPa
PaCo2>6.7kPa
what should target o2 sats be in copd patients?
88-92%
what type of masks should be used in copd patients and why?
Venturi masks
allow exact FiO2 to be administered (fraction of inspired o2)
What is the predominant inflammatory cell type seen in patients with COPD?
neutrophils
what are neutrophils?
polymorphonuclear granulocytes essential in the innate immune response
What is the predominant inflammatory cell type seen in patients with asthma?
eosinophils
aetiology of lung cancer?
smoking
other environmental agents - asbestos
radon gas
what are the 2 categories of lung cancer?
small cell
non-small cell (85%)
3 types of non-small cell lung cancer?
adenocarcinoma
squamous cell carcinoma
large cell
pathophysiology of adenocarcinoma nsc lung cancer?
commonest type, proportionally higher in non-smokers
carcinoma of mucus-secreting cells
occurs in lung peripheries
pathophysiology of squamous cell nsc lung cancer?
occurs in central part of lungs
often presents with pneumonia secondary to obstructed bronchus
mets occur late
histology shows keratin
pathophysiology of large cell lung cancer?
undifferentiated neoplasms
mets early
pathophysiology of small cell lung cancer?
fast doubling time, aggressive nature, early mets
cancer of the APUD cells
exclusively smokers, extremely poor prog
commonly associated with paraneoplastic syndromes
what type of cells are APUD cells?
neuroendocrine cells in lungs
clinical features of lung cancer?
commonly asymptomatic cough malaise weight loss haemoptysis SVC obstruction paraneoplastic syndrome
symptoms of lung cancer?
Fever Malaise Nausea Cough Haemoptysis Hoarseness Weight loss
signs seen in lung cancer?
Lymphadenopathy Stridor Wheeze Clubbing Hypertrophic pulmonary osteoarthropathy (HPOA) Signs of pleural effusion (exudative)
signs of pleural effusion (exudative):
stony dull percussion
reduced vocal fremitus
reduced breath sounds
what is superior vena cava obstruction?
when a lung cancer compresses the SVC
causes engorgement of the vessels in the neck and face, sob, and a fullness in the head - swelling
what is a pancoast tumour?
tumour of the superior sulcus in the lung
local spread may affect:
brachial plexus
cervical sympathetic trunk and stellate ganglion
subclavian vein
where is the superior sulcus/
groove in the first rib
what can pancoast tumours cause?
horner’s syndrome
shoulder pain radiating to arm and hand
atrophy of muscles in UL
oedema of UL
where do lung cancers commonly metastasise to?
what are the clinical features of these?
bone - pain, raised ALP
brain - focal/non-focal neurology
liver - abnormal LFTs
adrenals - asx
what are paraneoplastic syndromes?
remote effects of tumours unrelated to mass effect, invasion or metastasis
name some paraneoplastic syndromes commonly seen in lung cancer?
hypercalcaemia siadh cushings - sclc lambert-eaton syndrome hypertrophic osteoarthropathy
why does hypercalcaemia occur in lung cancers?
bony mets
tumour secretion of PTHrP, calcitriol
clinical manifestation of hypercalcaemia?
stones, groans, bones, thrones, psychiatric moans renal calculi bone pain abdo pain polyuria signs of altered mental status
what is hypertrophic osteoarthropathy?
clubbing and periostitis
symmetrical, painful arthropathy of distal joints
urgent referral for lung cancer if:
SCVO
stridor
2ww referral lung cancer if :
haemoptysis
>40, (ex/)smokers
suggestive cxr
strong clinical suspicion
when to get an urgent cxr in ?lung cancer?
suggestive features and history
special tests for lung cancer:
tissue biopsy endoscopy
from tumour, lymph node/metastasis
cytology
from aspirates, washings, pleural fluid
from tumour, LN, mets
what staging is used in lung cancer?
NSCLC: TNM staging
SCLC: VALSG staging
2 stages of VALSG staging SCLC?
limited disease: not beyond hemithorax, regional nodes, 1 RT field
extensive disease: beyond hemithorax, distant mets, malignant effusions, contralateral hilar/subclavicular involvement
management of NSCLC:
surgical lobectomy in stage 1/2 +LN sampling
chemo - neo-adjuvant, adjuvant
RT
management of SCLC:
surgery - only in very early disease (T1N0M0)
chemo
+ rt (together is mainstay)
2 types of pleural effusion:
transudates
exudates (high protein content)
what is a plerual effusion:
fluid within the pleural space
exudative causes of pleural effusion are often:
infective
inflammatory
malignant
transudative causes pleural effusion are often:
secondary to fluid overload or protein loss
CCF, nephrotic syndrome, hypoalbuminaemia
whos criteria is for exudative pleural effusion?
Light criteria
what do Light’s criteria state:
plerual effusion exudative if:
effusion protein:serum protein >0.5
effusion LDH:serum LDH>0.6
effusion LDH level>2/3 upper limit of the lab’s reference range for normal serum LDH
what is the tidal volume?
during normal breathing, the volume of air inspired and expired typically 500ml
over a minute where the RR is 12 this equates to 6L/min
what is the inspiratory reserve volume?
additional volume inspired with maximal effort (3L)
what is the expiratory reserve volume?
additional volume expired with max effort (1.2L)
what is the residual volume?
the volume that remains after the maximal expiration (1.2L)
what is the functional residual capacity?
combination of ERV and RV (2.4L)
what is the vital capacity?
volume of gas on maximal inspiration and expiration (5L)
what is total lung capacity?
total volume of gas in lungs at maximal inspiration
what happens to total lung capacity in obstructive and restrictive disease?
obstr - same or increase
restr - reduced TLC
what causes restrictive lung disease?
parenchymal, neuromuscular, chest wall diseases
what does peak flow indicate?
peak flow rate during the forced expiration following maximal inspiration
when is peak flow highest and lowest in day?
afternoon highest
early hours lowest
what does spirometry measue?
flow and volume of air, focuses on expiration
fev1, fvc
restrictive lung disease causes - PAINT:
intrinsic:
Pleural - pleural effusions, chronic empyema
Alveolar - oedema, haemorrhage
Interstitial - IPF, sarcoid
extrinsic:
Neuromuscular - MG, ALS
Thoracic - kyphoscoliosis, obesity, ascites
what happens to spirometry in restrictive picture:
FEV1: reduced
FVC: reduced
FEV1:FVC>0.8
what does a flow-volume loop show:
inspiration and expiration on y axis, while flow rate on x axis
pneumonia definition:
inflammation of the lung parenchyma
commonest routes of entry for pathogens causing pneumonia:
bacteria commonest
inhalation
aspiration
haematogenous
how is pneumonia diagnosed?
demonstrating acute consolidation on CXR
what causes consolidation on a CXR?
pus in alveoli
how can a CAP be divided?
into typical and atypical
commonest cause of a typical cap?
s.pneumoniae
hib
moraxella catarrhalis
common features of a typical pneumonia?
productive cough
fever
pleuritic chest pain
how do atypical caps usually present?
insidious onset
extra-pulmonary sx like malaise, arthralgia and headache, erythema multiforme
commonest causes of atypical pneumonia (cap)?
Nonzoonotic - mycoplasma pneumoniae, legionella pneumophila, chlamydophila pneumoniae
zoonotic - chlamydophila pssitaci (pssitocosis), coxiella burnetti (Q fever), francisella tularnsis (tularemia)
definition of a hospital acquired pneumonia?
pneumonia acquired >48hrs after admission
likely organisms for HAP:
gram negative bacilli: pseudomonas aeruginosa, staph aureus, legionella pneumophila
infective organisms causing aspiration pneumonias:
streep pneumo, saureus, hib, enterobacteriaceae, klebsiella
what is mendelsons syndrome?
chemical pneumonitis caused by aspiration of acidic gastric contents classically seen by obstetric anaesthetists
infective organisms causing pneumonia in immunocompromised:
mycobacterium, non-TB microbacterium
fungal - pneumocystis jirovecci, aspergillus fumigatus, cryptococcus neoformans
viral - varicella, cmv
parasitic
how is strep pneumoniae stained for?
Gram positive, alpha-haemolytic streptococci
what does strep pneumoniae do to blood tests?
leucocytosis and raised crp
what sputum in strep pneumoniae?
rust coloured
what is mycoplasma pneumoniae?
rod-shaped bacteria that lacks a cell wall
what is legionella?
causes?
gram negative coccobacillus
cooling systems, humidifiers, showers
what electrolyte finding is seen classically in Legionairre’s disease?
hyponatraemia secondary to siadh
also hypophosphataemia, raised ferratin
what is pseudomonas aeruginosa?
gram negative bacillus causing HAP
opportunistic (CF)
sputum in p.aeruginosa?
green
what is klebsiella pneumophila?
who is it commonly seen in?
gram negative bacillus
alcoholics
sputum in Klebsiella pneumophila?
red-current jelly
what is pneumocystis jirovecci?
fungus, AIDS-defining illness
common findings in pneumocystis jirovecci infection?
hypoxia, raised LDH
treatment of pneumocystis jirovecci?
co-trimoxazole (trimethoprim + sulfamethoxazole)
signs of pneumonia (clinical findings):
dull percussion note reduced breath sounds bronchial breathing coarse creps increased vocal fremitus tachycardia hypotension confusion cyanosis
pulmonary complications of pneumonia:
parapneumonic effusion
pneumothorax
abscess
empyema
extra-pulmonary cx of pneumonia:
sepsis
AF
what special tests for pneumonia: 1 blood and one other
CRP
urinary antigen testing (this does not delay abx)
CURB65 stand for?
Confusion Urea>7 Resp rate >30 BP <90/60 age>65 ON ADMISSION
general management measures for pneumonia ?
o2 titrated to sats
IV fluids
approproate analgesia
in low curb65 scoring CAP - Abx?
amoxicillin 5-7 days PO
or doxy/clarithro if pen allergic
intermediate severity CAP abx?
dual PO therapy amoxicillin + clarithromycin (doxy if pen allergic) 7-10 days
high severity cap abx?
IV beta-lactamase stable beta-lactam (coamoxiclav)
+ macrolide (clarithro) 7-14/7
HAP Abx: mild inf:
coamox 625mg TDS
HAP Abx: severe:
Tazocin (piperacillin/tazobactam) 4.5G TDS
what follow up care for pneumonia and why?
6/52 CXR - 11% smokers over 50 with pneumonia have lung cancer
define sarcoidosis:
multisystem granulomatous disorder of unknown aetiology
epidemiology of sarcoid:
20-50yos
blacks more commonly and worse affected
pathophys of sarcoid:
not fully understood BUT
immune dysfunction - T cell overactivity
noncaseating granulomas - epithelioid histiocytes
manifestation of pulmonary sarcoidosis:
interstitial lung disease - fibrosis
sarcoid on CXR:
bilateral hilar lymphadenopathy
reticular opacitities
main symptoms of sarcoid:
progressive sob
sarcoid sx OE:
fine end inspiratory crackles (also seen in IPF)
exertional desaturations
clubbing
cx of sarcoid:
pulmonary artery HTN
cor pulmonale
how does occular sarcoidosis present:
uveitis
keratoconjunctivitis sicca
adnexal granulomas
secondary glaucoma
what is uveitis:
inflammation of the uvea, structure composed of iris, ciliary body and choroid
another term for keratoconjunctivitis sicca?
dry eye syndrome
how does cutaneous sarcoid present?
RASHES
papular: head/neck
erythema nodosum: red, painful nodules
lupus pernio: nose, cheeks violaceous nodular
other manifestations of sarcoidosis?
hypercalcaemia (calcitriol) renal disease (nephrocalcinosis) CNS disease Arthralgia hepatosplenomegaly bone cysts cardiac involvement
heerfordt’s syndrome:
variant of sarcoid uveitis parotid swelling fever facial nerve palsy
lofgren’s syndrome:
acute variant of sarcoid bilat hilar lymphadenopathy erythema nodosum fever arthralgia
spirometry in sarcoid:
restrictive pattern
why do mantoux test if ?sarcoid?
rule out TB - another cause of bilateral hilar lymphadenopathy which causes erythema nodosum
blood findings: sarcoid:
serum ACE up
HRCT of sarcoid:
Lymphadenopathy
Diffuse nodularity
Ground glass opacification
Fibrosis typically affecting the upper lobes
Brochoalveolar lavage ± transbronchial biopsy:
sarcoid
inversion of CD4/CD8 ratio
raised lymphocytes
biopsy showing non-caseating granuloma
staging in sarcoid:
based on cxr 0 - N 1 - bilat hilar lymphadenopathy 2 - +infiltrates 3 - infiltrates alone 4 - pulmonary fibrosis
who gets tx in sarcoid:
symptomatic or stage 4
what is tx in sarcoid:
pred 20-40mg/day
lung transplant if end stage
upper lobe fibrosis: causes - breast
Bronchopulmonary aspergillus RT Extrinsic allergic alveotlitis Ankylosing spondylitis Sarcoid TB
lower lobe fibrosis causes: CRABS
cryptogenic fibrosing alveolitis (IPF) RA Asbesosis Bleomycin SLE, scleroderma
causes of erythema nodosum:
DIPS OUT
Drugs (sulfonamides) Infection (strep) Pregnancy Sarcoid Oral contraceptive pill UC (IBD) TB
causes of ILD:
Idiopathic pulmonary fibrosis Granulomatous (e.g. sarcoidosis) AI and collagen vascular disorders (e.g. rheumatoid) Inorganic (e.g. pneumoconiosis) Organic (e.g. farmers lung) Infective (e.g. tuberculosis) Drugs (e.g. amiodarone)
side effects of steroid use:
cushingoid
C - Cushing’s syndrome/cataracts U - ulcers (stomach) S - skin thinning/striae H - hypertension/hirsutism I - infections N - necrosis (avascular necrosis of the femoral head) G - glycosuria O - osteopaenia/osteoporosis I - immunosuppression D - diabetes
what causes TB and how does it spread?
mycobacterium tb/bovis/africanum/microti
respiratory droplets
how is multi-drug resistant TB being combatted?
multiple drug regimens and also a directly observed therapy (DOT) for adherence
3 features of microbacterium:
- obligate aerobes - require o2
- facultative intracellular - prefer to be intracellular
- acid fast bacilli - resistance to decolouriztion by staining by acid
In post-primary TB, what are the common manifestations?
Pulmonary TB 55%
Extra-pulmonary TB 45%
pathophys TB:
inhaled bacilli divide in alveoli - primary TB
host immune response
alveolar macrophages phagocytose bacilli
Ghon complex may develop -> Ranke complex
what is a ghon complex?
TB pathognomonic lesion seen in children where:
- Ghon focus (small caseating granuloma)
- lymphadenitis
- lymphangitis
what is a ranke complex?
a healed ghon complex seen in latent TB
what is Milliary TB:
haematogenous spread of TB
millet seeds on cxr - CNS involvement 20%
clinical triad of TB: pulm
fever
weight loss
cough
also sob, haemoptysis
how does Lymph Node TB appear:
firm, non-tender, enlarged
commonly cervical, supraclavicular
how does CNS TB present?
TB meningitis
fever, malaise, headache
what does CSF look like in TB meningitis?
high protein
low glucose
lymphocytosis
what is Pott’s syndrome?
TB in vertebrae
fever, weight loss, back pain
what does Adrenal TB commonly cause?
leading cause of Addison’s disease worldwide
diagnosis of latent TB:
mentoux test- IV hypersensitivity reaction +
Intraferon gamma release assay
diagnosis of active TB:
stains - acid fast bacilli - auramine O (Ziehl-Neelson)
cultures
PCR
what type of cultures id active TB?
Lowenstein-Jensen
4-6 weeks to get result
vaccine for TB? what needs doing first?
BCG
mantoux first
what type of vaccine is the TB vaccine? what does it also protect against?
live attenuated
leprocy
also treats bladder ca
ABx for TB? RIPE
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
side effects of TB abx:
R - LFTs, secretions pink, COCP null
I - polyneuropathy
P - hepatotoxic, gout
E- ON
who gets treated for latent TB:
adults <35 OR HIV+ OR healthcare workers AND mantoux test + >6mm - BCG CXR at risk groups
how long are doses of abx in latent TB?
6I
or 3RI
how long doses of abx given in active pulm TB?
(2HRZE, 4HR
how long doses abx given in pereicardial TB:
same as pulm TB but + pred
how is active CNS TB mx:
2HRZE, 10HR
pred
what is bronchiectasis?
permanent dilation of airways caused by chronic inflammation and inability to clear secretions
what are causes of bronchiectasis (congen/acquired)
congen:
CF
Young’s syndrome, Kartagener’s syndrome
acquired: post-infective
tumours
RA
IBD
what will CXR of bronchiectasis show?
tram track opacities of bronchi and bronchioles
what is pneumoconiosis?
disease of lungs due to inhalation of dust, characterised by inflammation, cough, fibrosis
where are the 3 respiratory centres in the brain?
pons respiratory centre
medullary respiratory centre
pre-Botzinger complex
which respiratory centre affects respiratory rhythm?
pre-Botzinger complex
exhibits pace-maker like activity on the medullary centre
where are the central chemoreceptors located?
ventrolateral surface of medulla
what are the central chemoreceptors sensitive to and what do they stimulate?
pH of the CSF - Co2 (NOT H+) can cross BBB (lipid sol)
stimulates/inhibits ventilation
how does a reduction in CSF pH affect ventilation?
increase in Co2 - increase in ventilation
where are peripheral chemoreceptors found?
carotid bodies - bifurcation - ph, o2, co2
aortic bodies - aortic arch - respond to o2, co2
which is more responsible to response of ventilation to raised co2 in blood - peripheral or central and which is faster response?
80% central - slower response
20% peripheral - faster response
define respiratory failure:
inadequate gas exchange in the lungs
what causes o2-induced hypercapnia, and what does not cause this?
caused by V/Q mismatch, hypoxic pulmonary vasoconstriction
Haldane effect
NOT desensitisation of resp centre to raised co2
what are o2-induced hypercapnic patients referred to as?
how are they managed?
chronic retainers (of co2) target o2 sats of 88-92%
what is the Haldane effect?
Hb increases its ability to carry co2 when deoxygenated
what is the Bohr effect?
Hb’s o2 affinity falls under acidic conditions
what is the diver’s reflex?
bradycardia, suppression of ventilatory drive and redirection of oxygenated blood to brain
Hering-Breuer lung inflation reflex:
inhibition of inspiration due to stimulation of stretch receptors on max inspiration
different types of pneumoconiosis:
coal miners pneumoconiosis bauxite fibrosis berylliosis asbestosis siderosis (iron) silicosis
what is a PE?
occlusion of pulmonary vasculature by a clot
causes of PE:
DVT air embolus fat embolus amniotic fluid embolus IVDU
what is a penumothorax?
air within the pleural space
causes of pneumothorax:
ruptured pleural bleb COPD TB sarcoid IPF RA Ank spond Lung cancer trauma asthma -> ADMIT any secondary pneumothorax
severe adult asthma attack mx?
nebulised salbutamol
Nebulised ipratropium bromide (given to all sev+Lifethreat)
PO Pred
patients with COPD who have had >3 exacerbations requiring steroid therapy and at least one exacerbation requiring hospital admission in the previous year. Prophylaxis with which drug should be considered????
azithromycin 6-12months
45-year-old man is prescribed bupropion to help him quit smoking. What is the mechanism of action of bupropion?
norepinephrine and dopamine reuptake inhibitor and nicotinic antagonist
(CI in epilepsy)
chest x-ray shows clear widenening of the mediastinum - ddx?
goitre, lymphoma and thoracic aneurysm may cause this finding
Lymphoma if night sweats
heart failure CXR:
Alveolar oedema (bat’s wings), Kerley B lines (interstitial oedema), Cardiomegaly, Dilated prominent upper lobe vessels, Effusion (pleural) are features of heart failure on a chest x-ray
deviated trachea on CXR indicates?
tension pneumothorax
AECOPD - started on amoxicillin and prednisolone by his GP. Since arriving in the department he has been given back-to-back nebulised salbutamol and ipratropium bromide. The oxygen concentration has been titrated to 28% to achieve a saturation of 88-92%. Due to his poor response to treatment an aminophyline infusion is started. next tx?
NIV
commonest org to cause AECOPD?
Hib
who do NICE recommend giving abx to in AECOPD?
if sputum purulent or clinical sx of pneumonia only
not all patients
AECOPD infective definition:
increasing dyspnoea, cough, wheeze
increase in purulent sputum
increase in hypoxia +- confusion
treatment of extrinsic allergic alveolitis?
avoidance of triggers
tx for sinusitis?
not abx in uncomplicated cases
patients with COPD who are dx with pneumonia tx:
Abx and steroids - even if no evidence of exacerbation
48-year-old male presents with a 8 week history of epistaxis and nasal stuffiness. On examination there is evidence of nasal crusting. A chest x-ray demonstrates multiple cavitary lesions. which antibodies are you ix for?
ANCA (c)
granulomatosis with polyangiitis (Wegners)
which organism most commonly causes a cavitating pneumonia in the upper lobes, mainly in diabetics and alcoholics?
klebsiella
patient with a background of COPD presents to the emergency department with a simple pneumothorax 2.2 cm in size. What is the most suitable management option?
chest drain
criteria for tx pneumothoracies:
1-2cm - aspirate first line
>2cm+SOB chest drain
<2cm without SOB - Discharge
stop smoking advice
which side is aspiration pneumonia more common on?
right lung
due to the larger calibre and more vertical orientation of the right main bronchus.
common in recently ET intubated people
Other than findings on respiratory examination, which observation makes the diagnosis of tension pneumothorax more likely than simple pneumothorax?
hypotension in tension pneumo due to low cardiac outflow (obsructed)
sign guidelines of escalating asthma mx:
- Oxygen
- Salbutamol nebulisers
- Ipratropium bromide nebulisers
- Hydrocortisone IV OR Oral Prednisolone
- Magnesium Sulfate IV
- Aminophylline/ IV salbutamol
The general signs of lobar collapse on a chest x-ray are as follows:
tracheal deviation towards the side of the collapse
mediastinal shift towards the side of the collapse
elevation of the hemidiaphragm
ARDS definition:
characterised by bilateral pulmonary infiltrates (“alveolar shadowing”) and hypoxaemia
71-year-old patient with a 2-month history of a cough and associated weight loss shows a suspicious lung mass on chest X-ray. Which of the following is the most appropriate next step?
contrast enhanced CT
his oxygen saturations are 60% on room air. He is in the tripod position and using his accessory muscles to breathe. His lips have a blue tinge to them. You note that he has been admitted to hospital several months ago and that he is known to retain CO2.
Which of the following methods of oxygen delivery would be most suitable
15L non-rebreathe
well controlled asthma on salbutamol (never used) and BD steroids - mx??
50% step down in steroid use then rv in 6months
What are the boundaries of the ‘safe triangle’ for chest drain insertion?
Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla.
type II respiratory failure. You are asked to consider non-invasive ventilation. At what pH is the patient most likely to receive benefit from non-invasive ventilation?
7.25-7.35 achieve the most benefit. If the pH is < 7.25 then invasive ventilation should be considered if appropriate
dextrocardia or complete situs inversus
bronchiectasis
recurrent sinusitis
subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)
these describe which inherited condition?
Kartagener’s syndrome
kartagener syndrome pathology?
dynein arm defect results in immotile cilia
Benign ovarian tumour, ascites, and pleural effusion. this indicates which dx?
Meig’s syndrome
what is the most common cause of an exudative pleural effusion?
pneumonia
what type of pleural effision when ethe protein level >35 and the LDH >200??
exudative
causes of transudative effusion?
heart failure
renal failure (hypoalbuminaemia)
hypothyroidism
meig’s syndrome
causes of exudative effusion?
- infection: pneumonia (most common exudate cause), TB, subphrenic abscess
- connective tissue disease: RA, SLE
- neoplasia: lung cancer, mesothelioma, metastases
- pancreatitis
- pulmonary embolism
- Dressler’s syndrome
- yellow nail syndrome
definition of exudative and transudative effusion?
exudative >30g/L protein
transudative <30g/L protein
dullness to percussion, reduced breath sounds and reduced chest expansion are all examination findings pointing towards????
pleural effusion
oedema signs on CXR:
lines! Kerley A lines, Kerley B lines and Kerley C lines represent expansion of the interstitial space by fluid.
55-yom -> GP 7/7 general fever and malaise, and a 2/7 non-productive cough. His eyes have also been sticky and sore for the last few days. appears visibly unwell, with a fever of 38.2ºC, RR 20. mild splenomegaly.
no hx recent travel and denies tuberculosis exposure/contact. He is, however, the proud new owner of George, a red-crested Australian King Parrot, who he has had for a month.
What is the most likely cause of this gentleman’s symptoms?
chlamydia psittaci
domesticated and exotic birds. C. psittaci classically causes a respiratory infection as well as an acute or chronic conjunctivitis
which lung ca is commonly associated with gynaecomastia, hypertrophic pulmonary osteoarthropathy (HPOA) and non-smokers????
adenocarcinoma
ambert-Eaton syndrome and syndrome of inappropriate anti-diuretic hormone (SIADH) secretion in which type of lung ca
small cell!
which lung ca associated with HPOA, parathyroid hormone-related protein secretion causing hypercalcaemia, and hyperthyroidism due to ectopic thyroid stimulating hormone secretion.??
squamous cell ca
smokers
pathology of hoarseness in lung ca?
seen with Pancoast tumours pressing on the recurrent laryngeal nerve - ix CT chest
Indications for corticosteroid treatment for sarcoidosis are:
parenchymal lung disease, uveitis, hypercalcaemia and neurological or cardiac involvement
Nasogastric tubes are safe to use if pH?
<5.5 on aspirate
if NG tube aspirate >5.5 - what do ya do?
CXR to look at placement of tube
inhaler technique advice:
after inhaling, hold breath for 10 seconds
second dose 30 seconds after the first
A 72-year-old gentleman presents to the respiratory clinic with worsening shortness of breath. On examination, he has obvious thoracic kyphosis. Assuming that this is the only cause of his breathlessness, which pulmonary function test results would you expect to see?
FEV1:FVC 85%, reduced gas transfer (TLCO) and increased KCO (transfer coefficient)
Extrapulmonary restrictive defect
KCO also tends to increase with age. Some conditions may cause an increased KCO with a normal or reduced TLCO:
pneumonectomy/lobectomy
scoliosis/kyphosis
neuromuscular weakness
ankylosis of costovertebral joints e.g. ankylosing spondylitis
COPD - still breathless despite using SABA/SAMA and a LABA + ICS → mx?
tiotropium prescription
add a LAMA
(use combination inhalers where poss to increase complaince)
what indicated in respiratory acidosis or rising PaCO2 resistant to best medical management during an acute exacerbation of COPD?
bipap (Niv)
Acute respiratory distress syndrome can only be diagnosed in the absence of a???
cardiac cause for pulmonary oedema (pulmonary capillary wedge pressure should not be above 15)
TRALI definition?
transfusion related acute lung injury - ARDS occurring within 6 hours of a transfusion taking place
normal chest x-ray an ex-smoker with shortness of breath, weight loss and hyponatraemia should be investigated???
for lung cancer - urgent referral to chest clinic
most effective mx to slow decrease of fev1 down in copd?
stop smoking
what tx should be given in a CAP on background of COPD even if no evidence of AECOPD?
pred
x-ray shows a large right sided hilar mass with resultant collapse of the right upper lobe. As a consequence the hyperexpanded right middle and lower lobes are hyperlucent (‘blacker’). in a 79M dx?
lung ca
A 52-year-old man who was born in India presents with episodic haemoptysis. His only history is tuberculosis as an adolescent. Chest x-ray shows a rounded opacity in the right upper zone surrounded by a rim of air.
dx?
aspergilloma
in hx of TB and round opacity on XR
A 71-year-old woman presents with dyspnoea and haemoptysis for the past two weeks. Clinical examination reveals a loud first heart sound, a diastolic murmur and new-onset atrial fibrillation.
dx?
mitral stenosis
haemoptysis secondary to rupture of the bronchial veins caused by raised left atrial pressure.
A 62-year-old woman who is being investigated for renal impairment presents with haemoptysis. On examination she has a flat nose.
dx?
granulomatosis with polyangitis
classic triad saddle nose, pulm haemorrhage, renal impairment
Scale is used in the identification of obstructive sleep apnoea????
epworth sleepiness scale for OSA
obstructive sleep apnoea risk factors:
4
obesity
macroglossia: acromegaly, hypothyroidism, amyloidosis
large tonsils
Marfan’s syndrome
cx of OSA:
daytime somnolence
compensated respiratory acidosis
hypertension
dx test and mx of OSA:
sleep studies - polysonmography
CPAP if respiratory acidosis (first line for osa after weight loss)
OD on which substance associated with respiratory alkylosis?
salicylate
respiratory alkalosis ddx:
5
anxiety leading to hyperventilation pulmonary embolism salicylate poisoning* CNS disorders: stroke, subarachnoid haemorrhage, encephalitis altitude pregnancy
When managing patients with COPD, once the pCO2 is known to be normal the target oxygen saturations should be???
94-98%
prevention of high altitude cerebral oedema medicine?
Acetazolamide
treatment of high altitude cerebral oedema medicine?
dex
chest x-ray shows a right basal opacity obscuring the right costodiaphragmatic recess with a meniscus, findings consistent with?
pleural effusion
COPD - still breathless despite using SABA/SAMA and no asthma/steroid responsive features →????
add laba+lama
what is recommended to start early in the course of COPD, as soon as patients start feeling shortness of breath with regular activity??
pulmonary rehabilitation
mx tension pneumothorax?
blunt cannula 14G (no CXR first - emergent) into 2nd intercostal space
after 1 PE, what makes the risk the greatest that they will have another PE in future?
if the first PE was unprovoked
24F episodic wheezing and shortness of breath for the past 4 months. She has smoked for the past 8 years and has a history of eczema. Examination of her chest is unremarkable. Spirometry is arranged and is reported as normal.
What is the most appropriate next steps?
FeNO test and spirometry with bronchodilator reversibility
Reversibility testing in adults, a positive test is indicated by an improvement in FEV1 of :
> 12% and >200ml volume increase
28-year-old man is in the surgical intensive care unit. He has suffered a flail chest injury several hours earlier and he was intubated and ventilated. Over the past few minutes he has become increasingly hypoxic and is now needing increased ventilation pressures. What is the most common cause?
tension pneumothorax in flail chest
56-yM -> ED with pleuritic chest pain, dyspnoea and pyrexia. PMH alcohol abuse and he smells strongly of alcohol. Starts coughing currant jelly sputum. You admit him and prescribe the appropriate antibiotics. You culture the sputum and the causative agent has been identified. Which other condition is associated with this organism too?
pleural empyema
klebsiella common in alcoholics
massive pleural effusion identification on CXR and mx?
meniscal line sueprio-lateral aspect, midline shift
pleural aspiration
trachea deviation away from side with effusion
COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features →
+LABA + ICS
In primary pneumothorax that has either shortness of breath or >2cm rim of air, mx
aspiration
COPD - still breathless despite using SABA/SAMA and a LABA + ICS →
add a LAMA (tiotropium)
Lower zones lung fibrosis: caused by which drug?
amiodarone
Before starting azithromycin do which ix?
ECG - r/o long QT (also CI in clari)
and baseline LFTs
can dx of COPD given if FEV1>80%?
yes if symptomatic of COPD and FEV1:FVC<0.7
DKA: metabolic acidosis with _______ anion gap?
raised
if moderate acute asthma attack, what feature of PMH would prompt admission?
previous near fatal attack
If a pleural effusion is drained too quickly, a rare but important complication that can develop is?
re-expansion pulmonary oedema
A 33-year-old woman is prescribed varenicline to help her quit smoking. What is the mechanism of action of varenicline?
nicotinic receptor partial agonist
if ? asthma what will response to aspirin be?
poor - will make sx worse
indications for surgery in bronchiectasis?
localsied disease (1 lobe) uncontrollable haemoptysis
COPD symptoms in a young person - think of which disease?
alpha-1-antitrypsin deficiency (A1AT)
could be a misdiagnosis of asthma too
Turbid effusion with pH<7.2, Low glucose, High LDH - dx?
empyema
all patients with an acute exacerbation of COPD in whom a respiratory acidosis (PaCO2>6kPa, pH <7.35 ≥7.26) persists despite immediate maximum standard medical treatment should get?
NIV (BiPAP)
64-M develops difficult breathing 15 hours post-emergency laparotomy. Fine crackles are heard on the right lower zone, and there is resonance on percussion. sats 96% on air, hr 78, respiratory rate is 16 , bp 110/68, and the temperature 38.1 ºC. A chest X-ray reveals a small area of airway collapse in the right lower lobe. dx, mx?
atelectasis
chest physio and breathing exercises
ix - cxr
resp causes of clubbing:
lung cancer pyogenic conditions: cystic fibrosis, bronchiectasis, abscess, empyema tuberculosis asbestosis, mesothelioma fibrosing alveolitis idiopathic pulmonary fibrosis
52-M 5/7 hx cough, feeling hot and facial pains. He is generally fit and well. DH: sertraline for anxiety and depression. He describes a cough productive of pale yellow sputum. He also describes difficulty breathing through his nose and pain in his face, particularly when coughing on leaning forward.
On examination he is alert, pulse rate is 84/min, temperature is 37.3º and respiratory rate is 16/min. His blood pressure is 122/74 mmHg. Chest auscultation is unremarkable. He is tender over the maxilla. dx?
viral URTI
progressive asbestos changes lungs:
pleural plaques - benign
pleural thickening
asbestosis
mesothelioma
Indications for corticosteroid treatment for sarcoidosis are:
parenchymal lung disease
uveitis
hypercalcemia
neuro/cardiac involvement
asbestos: which lobes affected? most dangerous form? severity related to? can you get mesothelioma with limited exposure?
lower lobes
blue crocidolite asbestosis
related to length of exposure
yes
mesothelioma diagnosis confirmed by?
histology following biopsy from thoracoscopy
heroin addict ABG?
respiratory acidosis due to hypoventilation
67M progressive exertional dyspnoea. These symptoms have been getting progressively worse over the past nine months and are associated with a dry cough. He gave up smoking 20 cigarettes/day around 30 years ago. On examination his oxygen saturations are 97% on room air, respiratory rate is 14/min and there are some fine bibasal crackles. Finger clubbing is noted. dx?
idiopathic pulmonary fibrosis
note in history: exertional
allergic bronchopulmonary aspergillosis (ABPA) in CF patient. First-line tx?
Prednisolone
Itraconazole 2nd line
obstructive picture with normal/raised total gas transfer (TLCO) with raised transfer coefficient (KCO): causes: (2)
asthma
pulmonary haemorrhage
Sudden deterioration with ventilation suggests which condition?
tension pneumothorax
28-M. trying for children for the last 2 years. His wife has had 2 children already. PMH: repeated chest infections and repeated bouts of otitis media. frequent URTIs requiring abx. This is an ongoing problem since childhood. He believes that there is something wrong his genital tract. His right testicle hangs lower than his left. Apex beat is in the 5th intercostal space on the right midclavicular line. dx?
kartageners syndrome
primary ciliary dyskinesia
58-F -> GP 5/7 hx mild SOB with exertion. Associated cough and productive sputum 3/7 ago. Prior to this, she had a runny nose, mild headaches and generalised muscle fatigue. No fever, chills or rigour. BG: of poorly-controlled COPD and T2DM, in which she is currently taking salbutamol puffers as required, regular metformin and insulin.
Grandson had a fever and purulent cough, and an associated exanthematous rash 2/52 ago which had resolved spontaneously. She does not smoke and drinks 2 standard drinks a day.
Appears well and rested. Obs are stable. Bilateral scattered wheeze bibasally and no increase in vocal resonance. next step in management?
po amoxicillin (doxy if allergic)
in bronchitis if co-morbidities, tx with abx
chest x-ray shows multiple nodular opacities in the upper lobes which are commonly seen in a restrictive spirometry picture - dx?
pneumoconiasis
on cxr: The loss of the left heart border is a classic sign of???
left lingula consolidation
(FEV1:FVC >70%, decreased FVC) and impaired gas exchange (reduced TLCO, KCO) - dx?
idiopathic pulmonary fibrosis
asbestosis spirometry?
restrictive
cannonball mets - think which ca?
RCC - ix CT abdo
lung ca hx with Difficulty walking and muscle tenderness?
LEMS features -> small cell
secondary pneumothorax 1-2cm without breathlessness - mx?
aspiration
which RA drug most likely caused Bilateral interstitial shadowing on CXR?
MTX
pneurmonia vs bronchitis - how to differentiate ?
pneumonia = SOB, obs would be off, would have focal examination sx, sputum, wheeze
Bronchiectasis: most common organism =
hib
green sputum
Asthmatic features/features suggesting steroid responsiveness in COPD:
previous diagnosis of asthma or atopy
a higher blood eosinophil count
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)
A normal PaCO2 in an acute asthma attack indicates???
exhaustion and should therefore be classed as life-threatening asthma -> ITU
Alpha1-antitrypsin deficiency can be diagnosed prenatally using???
chronic villus sampling 11-14/40
amniocentesis - 15-20/40
surgical treatment of alpha-1 antitrypsin deficiency?
lung volume reduction surgery
chest drain swinging = ?
water seal rising on inspiration and falling on expiration
commonest causes of an anterior mediastinum mass can be remembered by the 4 T’s:
Teratoma
terrible lymphadenopathy
thymic mass
thyroid mass
30-F->ED 2/12 hx diplopia. Increasing fatigue and weakness, especially at the end of the day. She is found to have anti-acetylcholine receptor antibodies. CT chest: anterior mediastinal mass.
What is this anterior mediastinal mass most likely to be?
thymoma -> MG
30M PMH asthma presents with a 5/7 hx cough and wheeze. He currently takes salbutamol prn and beclometasone 200mcg bd. His peak flow is 70% of normal. tx?
5 day course PO Pred
steroids in all acute cases of asthma
The features of acute severe asthma are:
PEFR 33-50% best or predicted, inability to complete full sentences, RR >25/min and pulse >110 bpm
71M being investigated for recurrent collapse during exertion presents with progressive shortness of breath. His pulse is 84 / min and blood pressure 110/90 mmHg. dx?
aortic stenosis
Pt has hx recurrent pulmonary embolism despite anticoagulation with warfarin. Changes would be expected on spirometry?
reduced TLCO
caused raised TLCO:
asthma pulmonary haemorrhage (Wegener's, Goodpasture's) left-to-right cardiac shunts polycythaemia hyperkinetic states male gender, exercise
causes reduced TLCO:
pulmonary fibrosis pneumonia pulmonary emboli pulmonary oedema emphysema anaemia low cardiac output
Pregnant women who smoke: cessation options:
Nicotine replacement patches
varenicline and bupropion are contraindicated
diagnostic ix for IPF?
high-resolution CT
A 24-year-old female presents with facial weakness, fever and painful red eyes. On examination you note a left sided facial palsy and tender swelling of the parotid glands. Laboratory results reveal a calcium level of 2.82 mmol/L. dx?
sarcoid
hypercalcaemia seen
is prednisolone safe to take while breastfeeding after acute asthma attack?
yes
all asthma drugs safe to continue in preg too
45f-> GP with a new rash on her face. Raised purple lesion covering the nose, cheeks and lips. Dx rosacea however it has rapidly progressed. Also notes axillary and inguinal lymphadenopathy. Fatigue as well as some dyspnoea over the last 6 months. She has smoked 10 cigarettes a day for the last 8 months and drinks 10 units of alcohol a week. dx?
sarcoid
what will CRP and WCC do in treatment of acute bacterial infection (eg CAP)
CRP lags behind the WCC so if clinically improving but crp increases could be a lag
CI for chest drain?
INR>1.3
plts<75
bullae, adhesions
lung nodules in the context of rheumatoid arthritis (RA) - which syndrome?
caplan
70M->ED 1/52 worsening dyspnoea. 50 pack-years. No hx trauma, fever, productive cough, or weight loss.
Hyper resonance and reduced breath sounds on the upper right hand side. CXR large lucent areas over the right lung without a visible wall. Chest tube was inserted under the presumed diagnosis of a spontaneous pneumothorax. No symptomatic relief. Follow-up CXR reveals no improved expansion of the right lung. dx?
large bullae in COPD can mimic pneumothorax
42-M->ED acute severe asthma. Beta-agonist by nebuliser, and oral steroids. After a few hours
his asthma is better but he develops weakness in both legs and finds he is unable to get up from his chair. why?
hypokalaemia due to salbutamol
noc CF bronchiectasis mx?
Symptom control in non-CF bronchiectasis - inspiratory muscle training + postural drainage
ipratropim??
SAMA
25F 2/7 hx sob. pain in both knees as well as alopecia and oral ulcers. Rash on the cheeks and nose is observed. Dull percussion notes and diminished breath sounds are noted in both lower lung fields. A chest radiograph demonstrates bilateral pleural effusion. ix, dx?
ANA
SLE
pleural fluid aspiration is performed. The appearance of the fluid is clear and is sent off for culture. Whilst awaiting the culture results, which one of the following is the most important factor when determining whether a chest tube is placed?
pH
Contraindications to lung cancer surgery include ??
SVCO
FEV<1.5
malignant pleural effusion
vocal cord paralysis
British Thoracic Society suggest X is a factor making asthma less likely?
peripheral tingling when sob
1st line for acute bronchitis?
doxy
which arrhythmia can be caused by tension pneumothorax?
PEA- reversible
