Respiratory Flashcards
What is COPD?
A progressive obstructive lung disease, characterised by airflow limitations which are not fully reversible
What are histological changes you would find in COPD
Increased goblet cells
Enlargement of mucus secreting glands
What WBC are involved in COPD
macrophages but not eosinophils
A 70 year old male with an extensive smoking history presents to you. He has - productive cough - SOB on excessive - feeling tiered - Wheeze
What is his diagnosis?
COPD
What changes cause the increased resistance in the airways in COPD
decreased elasticity
fibrotic changes
luminal obstruction
What type of respiratory failure is characteristic in COPD
Type 2
What test is diagnostic for COPD and
What is the diagnostic cut off?
Spirometry, an FEV:FVC <0.7 post bronchodilator
What are possible consequences of COPD
pneumonia
pneumothorax
pulmonary hypertension
What investigation is most useful in a COPD exacerbation (excluding PFT). What may that show?
CXR may show hyperinflation (not linked to exacerbation) also pneumonia or pneumothorax.
Signs of:
Flattened diaphragm and increased retrosternal air space volume, indicating lung hyperinflation
Hyperlucency of the lungs
Rapid tapering of vascular markings
A patient has an FEV1 (% predicted) of >80 what is his GOLD grade
GOLD 1
A patient has an FEV1 (% predicted) of 50-70 what is his GOLD grade
GOLD 2
A patient has an FEV1 (% predicted) of 30-49 what is his GOLD grade
GOLD 3
A patient has an FEV1 (% predicted) of <30 what is his GOLD grade
GOLD 4
BREAK CARD - LOOK OVER ALL OF COPD QUICKLY
TAKE 5 MINUTES
A Patient has a mMRC=2+/ CAT >10 (mod-sev symptoms)and has had 0-1 exacerbations in the last year not requiring hospitalisation. What is his ABCD score (GOLD ABCD for COPD)
B
A Patient has a mMRC=0-1 / CAT <10 (mild-mod symptoms) and has had 2 + exacerbations in the last year or 1+ requiring hospitalisation. What is his ABCD score (GOLD ABCD for COPD)
C
A Patient has a mMRC=2+/ CAT >10 (mod-sev symptoms)and has had 2 + exacerbations in the last year or 1+ requiring hospitalisation. What is his ABCD score (GOLD ABCD for COPD)
D
How would you manage a patient in group A of (GOLD ABCD COPD)
SABA or LA Bronchodilator depending on effects of bronchodilator
How would you manage a patient in group B of (GOLD ABCD COPD)
LA Bronchodilator, if that is ineffective dual LA Bronchodilator therapy (SABA PRN)
How would you manage a patient in group C of (GOLD ABCD COPD)
Start on LA Bronchodilator, second line is dual LA Bronchodilator. If that is ineffective LABA + ICS (SABA PRN)
How would you manage a patient in group D of (GOLD ABCD COPD)
Start on dual LA Bronchodilator, if that is ineffective LABA + LAMA + ICS (triple therapy) and then LABA + ICS (SABA PRN)
What other therapies (not medical) are used regardless of GOLD ABCD in COPD
smoking cessation
Patient Vaccines
When would pulmonary rehabilitation be used in COPD
from group B-D
What is Theophalline (and aminophylline) and when would it be used in COPD
a xanthine, used to treat wheezing and SOB in chronic lung conditions.
In COPD it is an adjunct from group C-D
When would a phosphodiasterase 4 inhibitor be used in COPD, what does it do
group D and down regulates inflammation
when would a macrolide antibiotic be used in COPD, give two examples
in group D.
Examples would be Azithromycin or Clarithromycin
In what groups of COPD patients is O2 therapy indicated
group B - D
How would you investigate an exacerbation of COPD
FBC ECG CXR ABG Pulse Ox Sputum Cultures
How would you manage a COPD patient with exacerbation causing, fever, increase SOB, low O2 on air, and an increase in sputum (green colour) but no acidosis
Empirical antibiotics until more specific antibiotics can be used
What ventilation is indicated in COPD patients
NIV - BiPAP
Wha are the indications for ventilation in a COPD exacerbation
very low O2 sats
Respiratory acidosis
haemodynamic instability
What pathogens most commonly cause the common cold
rhinovirus (50%)
then: Coronavirus influenza parainfluenza RSV
A 5year old child presents to you with acute onset (1-2d) rhinitis, sore that, fever 38’c. On examination the back of his treat is red and inflamed
he is otherwise well
what is the diagnosis?
Common cold
What is the Fever Pain/ Centor criteria
criteria to determine if tonisitis is most likely bacterial
FeverPAIN criteria
Fever (during previous 24 hours)
Purulence (pus on tonsils)
Attend rapidly (within 3 days after onset of symptoms)
Severely Inflamed tonsils
No cough or coryza (inflammation of mucus membranes in the nose)
Centor criteria
Tonsillar exudate
Tender anterior cervical lymphadenopathy or lymphadenitis
History of fever (over 38°C)
Absence of cough
What pathogens commonly cause tonsillitis
rhinovirus
coronavirus
adenovirus
Group A streptococcus (B haemolytic)
What investigations might you like to carry out if you suspect bacterial tonsillitis
throat culture
rapid streptococcal antigen test
What is the management of viral tonsillitis
analgesia
What is the management of bacterial tonsillitis
analgesia
phenoxymethylpenicillin, 2ry Abx choice is azythromyocin
+/- dexamethasone if a patient has severe swelling
What is the criteria needed to get a tonsillectomy
7+ in one year
5+ in 2 years
3+ in 3 years
What is pharyngitis
can be difficult to distinguish from tonsilitis
is an acute onset of sore throat and pharyngeal inflammation
What pathogens can cause pharyngitis commonly
EBV, adenovirus, enterovirus
Group A strep, ghonnorhea, chlamydia
candida - immunocompromised
A 10 year old child presents to you.
They present to you with a very sore throat, on further examination you notice there is conjunctivitis and the beginning of a maculopapular rash.
You notice on their history that have not had Imms
What is the diagnosis? What sign would you find inspecting the mouth?
Measles
Koplick spots
Conjunctivitis and kopeck spots suggest easy stages of measles
A 14 year old child presents to you after having recently immigrated from India.
They have a high fever, barking cough, sore throat and lymphadenopathy. On inspection of the mouth you notice a grey adherent pseudomembrane.
What is the diagnosis?
Diptheria
What are the diagnostic investigations for diphtheria?
bacterial culture (throat) and microscopy
What is the treatment of Diptheria?
admit to hospital
diphtheria antitoxin
plus Benzylpenicillin sodium
Airway protection/intubation may be needed
Imms given
What do close contacts of someone diagnosed with dipheria require
erythromycin base
What is sinusitis?
symptomatic inflammation of the mucosal lining of the nasal cavity and paranasal sinuses. Usually symptoms last less than 4 weeks
What pathogens cause sinusitis?
Viral:
Rhinoviruses, influenza viruses, and parainfluenza viruses
Bacterial causes :
S. Pneumoniae and H Influenza
A patient presents to you with purulent nasal discharge, nasal congestion, facial pain and pressure by eyes/nose.
What is the diagnosis?
Viral sinusitis
A patient presented to you 5 days ago with what was thought to be viral sinusitis. They said that after their initial visit to you it has been getting worse.
What do you suspect? And what is the treatment?
its bacterial sinusitis
Amoxicillin/clavalanate
2ry option is clyndamycin
plus decongestants/iintranasal corticosteroids (mometasone) and ipatropium (anticholinergic) for rhinorrhea
What is the treatment for viral sinusitis
supportive therapy:
decongestants
intranasal corticosteroids (mometasone)
and ipatropium (anticholinergic) for rhinorrhea
what is asthma?
A chronic inflammatory airway disease with intermittent reversible airway obstruction and hyperactivity
A young patient comes in. They have been experiencing SOB, particularly worse in the morning and evening. They have noticed that cold air and exercise make symptoms worse and they develop a cough/
What is the most likely diagnosis?
Asthma
What kind of wheeze is associated with asthma ?
expiratory
What are risk factors for having asthma?
family history
eczema
Hayfece
(atopty)
what is FVC?
The force of air which can be forcibly and maximally expired out of the lungs after having filled the lungs with air. It is all of the air in the lungs apart from the residual volume.
What is FEV1?
The total amount of air which can be forcibly expired in one second after having maximally inspired.
what is the FVC/FEV1 ratio in asthma?
Should be less than 80% of the predicted value for the individual’s age height weight and ethnicity.
What is the first line diagnostic test in asthma?
Bronchodilator trial
What results would you expect to see in an asthmatic during a bronchodilator trial?
For the diagnosis of asthma there has to be a 12% improvement in FVC/FEV1 after bronchodilator therapy
how are lung functions measured?
Using spirometry
How is asthma monitored?
Peak expiratory flow rate
How would you classify the following symptoms of asthma:
symptoms less than twice a week
asymptomatic and normal peak expiratory flow rate between the attacks
attacks are brief with varying intensity
night-time symptoms occur less than twice a month
FEV1 or PEFR greater than 80% of predicted
PEFR variability is less than 20
Mild intermediate asthma
How you classify the following symptoms of asthma:
symptoms more than twice a week but usually less than once a day
when exacerbations are present they affect daily activities
the night-time symptoms more than twice a month
FEV1 is greater than 80% of predicted value
PEFR variability is between 20 and 30
Mild persistent asthma
How would you classify the following symptoms of asthma:
daily symptoms
use of SA BA daily
attacks affect daily activity
exacerbations are more than twice a week and may last for days
night-time symptoms present more than once a week
FEV1 is between 60 to 80% of predicted
PEFR variability is over 30
Moderate persistent asthma
How would you classify the following symptoms of asthma: continual symptoms Limited physical activity frequent exacerbations frequent nighttime symptoms FEV1 is less than 60% of predicted PEFR variability is over 60%
Severe persistent asthma
Describe a stepwise management of asthma
- SABA PRN
- ICS (low) (alternative cromolyn or montelukast)
- ICS (med)
- ICS (med) + LABA or Monetleukast
- ICS (high) + LABA or Monetleukast
- ICS (high) + LABA or Monetleukast + PO CS
What is the definition of an asthma exacerbation
An acute or subacute episode of progressive worsening symptoms and decreased baseline pulmonary function tests
What causes asthma exacerbations
Exposure to irritants
viral or bacterial infections
non-compliance to medication
How does an asthma exacerbation present
Presents with worsening of previous symptoms those are: cough wheeze chest tightness sleep disturbances signs of respiratory distress
What are some signs of respiratory distress
Use of accessory muscles tachyopnea tachycardia poor air movement diminished breath sounds
How would you investigate an exacerbation
do pulmonary function tests (peak flow is quick and safe)
measure O2 saturations
in severe exacerbations the following may be used
ABG
chest x-ray
+ cultures
A patient with an asthma exacerbation comes in with:
shortness of breath with activity
their PEF is over 70% of the predicted or personal-best
what is the severity of their exacerbation
Mild
A patient with an asthma exacerbation comes in with:
shortness of breath that interferes with usual activity
PEF is between 40 to 69% of predicted
what is the severity of their exacerbation
Moderate
A patient with an asthma exacerbation comes in with:
shortness of breath at rest
unable to complete a full sentence
pulmonary function tests are less than 40% of predicted
what is the severity of their exacerbation
Severe
A patient with an asthma exacerbation comes in with: severe shortness of breath possible reduction in consciousness too short of breath to speak perspiring PEF is less than 25% of the predicted
what is the severity of their exacerbation
Life threatening
How do manage a mild exacerbation (asthma)
Give 4-8 puffs of inhaled salbutamol every 20 minutes in four hours and then slowly decrease
you can give an adjunct per oral steroid- prednisolone for five days or until resolution
How do you manage a moderate to severe exacerbation?
Gives nebuliser salbutamol ideally nebulised with oxygen
give per oral steroids
give ipratropium bromide
give magnesium sulphate
if you suspect an impending respiratory failure data ICU and consider mechanical ventilation
if life-threatening cortical Hydro steroid IV can also be given
What is hypersensitivity pneumonitis?
Inflammation of the alveoli and distal bronchioles caused by an immune response to inhaled allergens
What are the causes of hypersensitivity pneumonitis
Bird droppings – bird fancier's lung compost lung farmers lung chemical workers lung lab work as lung
What are the three types of hypersensitivity pneumonitis?
Acute – occurring hours after exposure
subacute – developing weeks to months following exposure
chronic – developing months to years after exposure
What are the symptoms of hypersensitivity pneumonitis?
Flulike: shortness of breath non-productive cough (acute) or productive cough (sub acute or chronic) fever malaise weight loss especially in chronic
on examination you might find bibasilar rails, diffuse rails, clubbing.
A patient presents to you with progressively worsening shortness of breath, weight loss and productive cough.
They say they occasionally get fevers and that symptoms get worse
they also say that their work is of a farmer
what is the diagnosis?
Hypersensitivity pneumonitis
How would you investigate hypersensitivity pneumonitis
pulmonary function tests
Blood tests checking for immunological responses to causative antigen
chest x-ray or CT
full blood test (+WCC) ESR(+)
What might you find on a chest x-ray for hypersensitivity pneumonitis?
what about on CT?
X-rays show modular patchy infiltrates
CT shows ground glass shadowing central though bar nodules with relative basal sparing
What pattern would you see on the pulmonary function tests of hypersensitivity pneumonitis?
Acute tends to be restrictive
subacute and chronic have a mixed restrictive obstructive pattern
How do you treat hypersensitivity
pneumonitis?
Avoiding triggers
corticosteroids, prednisolone, either short-term if acute or subacute or long-term chronic
What is occupational asthma?
Asthma caused by workplace and may result from immunological or non-immunological stimuli
What are the two types of occupational asthma?
Sensitiser induced which is immunological
irritant induced which is non-immunological
Which type of occupational asthma has a latency period?
Sensitiser induced i.e. immunological
what is the typical causative agent of community-acquired pneumonia?
What are other causes?
Streptococcus pneumonias
haemophilus influenza
Staphylococcus aureus
group A Streptococcus
What are the causative agents of atypical pneumonia?
Mycoplasma pneumoniae
Legionella
What tool is used to help assess whether or not to admit the patient to hospital with community-acquired pneumonia?
CURB 65
What a risk factors for community-acquired pneumonia?
Over 65 residents in a nursing home contact with children respiratory chronic diseases alcohol and smoking misuse poor oral hygiene PPI and H2 antagonists
what might the presentation be with pneumonia community acquired?
Cough increased sputum shoppers of breath chest pain pleuritic rigors night sweats fever confusion myalgia malaise
What is the most predictive feature on examination for community acquired pneumonia?
tachypnea
for community-acquired pneumonia what findings would you find on examination of the lungs?
tachypnea Crackles decreased breath sounds dullness on percussion wheeze
Apart from lung examinations what else would you like to do on initial assessment when assessing a patient with community-acquired pneumonia?
Check pulse oximetry anything less than 94% on air would require O2
What is the gold standard for diagnosing community-acquired pneumonia?
chest x-ray: showing consolidation
What is the management of a low curb score for community-acquired pneumonia?
Start empirical oral antibiotic treatment
encourage fluids and paracetamol
only consider hospital if particularly stable have severe risk factors all namesake peril medications
What is the management of moderate curb Score for community-acquired pneumonia?
Make a hospital referral
in-hospital supportive care and empirical IV antibiotics
what is the management of a severe curb score for community-acquired pneumonia?
Urgent hospital admission and starting oral empirical antibiotics prior to hospital admission
it
once in hospital supportive care and continue empirical antibiotics Ivy and consider fluoroquinolone
What antibiotics are typically used for Streptococcus pneumonia in community-acquired pneumonia?
amoxicillin – oral, benzylpenicillin – IV
What is the management of MRSA community-acquired pneumonia?
Vancomycin IV with or without rifampicin ( oral or IV)
What antibiotics would use for H influenza community-acquired pneumonia?
AmoxicillinIf beta lacks in producing ad in clavulanate
what antibiotics are used for staphyylococcus pneumonia?
Flucloxacillin with or without rifampicin
Why is fluroquinolone used in broad-spectrum severe community acquired pneumonia?
It covers atypical Pneumonias mostly Legionella
another antibiotic which Legionella is responsive to is azithromycin
When does Legionella typically occur?
After exposure to contaminated air conditioning
Describe the CRUB 65 score?
Confusion (1) urea elevated (1) respiratory rate over 30 (1) blood pressure, low (1) aged over 65 (1)
low = 0-1
moderate=2
severe=3-5
What is hospital-acquired pneumonia?
and acute lower respiratory tract infection acquired after at least 48 hours of admission to hospital. And wasn’t incubating at the time of admission
What pathogen is usually because hospital-acquired pneumonia?
Mainly gram-negative bacteria
commonly Pseudomonas Aeruginosa, E.Coli, Kebisella pneumonia or staph. Aureus inc MRSA
What risk factors are associated with hospital-acquired pneumonia?
Poor infection control and intubation
Diagnostic criteria for hospital-acquired pneumonia?
Positive imaging on x-ray +2 clinical features of:
fever over 38°C
leucocytosis or leukopenia
purulent secretions
While investigations might you like to perform in hospital-acquired pneumonia?
chest x-ray showing consolidation
white cell count (+)
pulse oximetry(-)
culture of lower respiratory tract sample during bronchoscopy
What is the management of hospital-acquired pneumonia?
- X rays and bloods
- take cultures
- start broad-spectrum empirical IV antibiotics (cefepime)
If hospital-acquired pneumonia is not severe what antibiotics could you give?
Oral indicated if non-surveyor and there is low risk of resistance
give Comox a glove or doxycycline if allergic to penicillin’s
What antibiotics would you give to cover Enterobacters?
Meropenem
What is a bronchiectasis?
The permanent sanitation of the bronchitis you to the destruction of elastic and muscular components of bronchial wall. Often caused as a consequence to recurrent chest infections and secondary to an underlying disorder.
What is the presentation of bronchiectasis?
Most commonly presenting with a productive cough
cough may get worse and lying down
fatigue shortness of breath, haemoptysis
history of underlying lung disorder or chronic infections
What is the most common identifiable risk factor for bronchiectasis?
Cystic fibrosis
What is a diagnostic test for bronchiectasis?
Chest CT
What would a chest CT show in bronchiectasis?
Airway dilatation with or without airway thickening
fluid
cysts - in a tree bud pattern
varicose constrictions
What would pulmonary function tests show in bronchiectasis?
A decrease in FEV1
an increase in RV and TLC
What other underlying chest pathologies apart from cystic fibrosis predisposed to bronchiectasis and what other diagnostic tests?
A1 ATD - cerium A1AT
ciliary dyskinesia - nasal nitric oxide
lung infections- sputum culture
How do you manage bronchiectasis?
Healthy lifestyle and pulmonary rehab
as ABA with or without meuco active agents (nebulised saline)
in an exacerbation manage that
What is cystic fibrosis?
A severely life shortening genetic disease resulting from abnormalities in the CF TR gene.
Most commonly affecting the lungs but also causes pancreatic involvement and liver involvement and intestinal involvement and reproductive involvement
What is the pathophysiology of cystic fibrosis?
Mutations are caused by abnormal salt transportation (Na+, Cl-)
this causes a thickening of secretions and a reduction in our liquid layer with impaired ciliary function.
In the lungs: causes of mucus retention leading to chronic infection and inflammation resulting the destruction of lung tissue
in the intestines: bulky stores lead to intestinal blockage
in the pancreas: blockage of exocrine ducts occur. This causes the early activation of pancreatic enzymes and auto-destruction of pancreas
When is the diagnosis of cystic fibrosis usually made?
What is a test?
Usually made on a positive newborn heel prick screen
If undiagnosed at the newborn heel prick screen what is the presentation of cystic fibrosis?
Failure to pass meconium
Male genital abnormalities (no vaster variance)
failure to thrive insatiable appetites (due to pancreatic insufficiency)
chronic sinusitis
prolonged severe coughs and colds which are wet sounding
recurrent chest infections
Apart from the heel prick screen test what other diagnostic test is that for cystic fibrosis?
Sweat test
the ultimate diagnosis is made by genetic testing
What is the lung management of cystic fibrosis?
- chest physiology with S ABA and new politically agents
adj. inhaled tobramycin ( and antibiotic given to children over six years for chronic pseudomonas infections) - anti-inflammatory agents: azithromycin/fibre proven or prednisolone or inhaled corticosteroids
- CFT art modulator: Ivacaftor
- bilateral lung transplantation
How do you manage the GI manifestations of cystic fibrosis?
Monitor and optimise nutrition
if affecting pancreas…
using pancreatic enzymes, fat-soluble vitamins supplements
If causing gord…
Ranitidine or lansoprazole
Urodeoxycolic acid acid
What are the complications which can arise in neonates due to cystic fibrosis?
Meconium ileus
distal intestinal obstruction
peritonitis
What is the management of meconium ileum or intestinal obstruction?
Insert nasogastric tube for decompression
close fluid and at electrolyte balance with Ivy
water-soluble contrast enema plus an oral osmotic agent (lactulose) - only if not complete obstruction or peritonitis. hasn’t occurred
surgery
how would you manage acute respiratory failure caused by a mild exacerbation of cystic fibrosis?
Oral antibiotics (amoxicillin) increasing chess physio SABA inhaled mutilated adjunct inhaled tobramycin
How would you merge acute respiratory failure caused by a severe exacerbation of cystic fibrosis?
Iv tobramycin antibiotics for specific pathogens chest physic increase S ABA Inhaled mucolytic
How often do you have to monitor patients with cystic fibrosis?
Every three months with a CF care team
what is involved in the monitoring of cystic fibrosis?
History
exam respiratory
and spirometry
yearly there should be test x-rays bloods and full pulmonary function tests
What is tuberculosis?
An infectious disease caused by Mycobacterium tuberculosis
it is a notifiable disease
What is the biological history of tuberculosis?
Droplets and hills and they get deposited in the alveoli
macrophages engulf mycoplasma tuberculosis however it survives and replicates within the macrophage
the M TB kills host macrophages and then is released causing an immune response
T cells and macrophages form a granuloma with necrotic KCS centre trapping MTB here begins the dormant phase
10% of individuals progress to active disease usually after a new no compromise Asian
What are the risk factors involved in tuberculosis?
poor living conditions
exposure to TB
but an endemic country (Asia, Latin America, Africa)
HIV infection
immunosuppressant
silicosis
apical fibrosis
What is the to presentation of tuberculosis?
Cough
low-grade fever
anorexia
weight loss
malaise
night sweats
haemoptysis
What investigations are required in Tuberculosis?
Chest x-ray sputum acid-fast bacilli smear (+) sputum culture (+) FBC ( - HB, + WCC) nucleic acid amplification test
What test is used for latent TB?
Mantoux test
What would you find on x-ray in tuberculosis patient?
Nodular opacities in the upper lobes
When is a Mantoux test positive if the swell is greater or equal to 5 mm?
HIV positive
recent contact with an active TB patient
nodular or fibrotic changes on chest x-rays
organ transplant
When is a Mantoux test positive if the swell is greater or equal to 10 mm?
Recent arrivals (less than five years) from home: countries
IV drug users
resident or employee of a high-risk setting
mycobacterial lab personnel
comorbidity
children under four years old
adolescents and anyone younger exposed to high-risk categories
When is a Mantoux test positive if the swell is greater or equal to 15 mm?
Persons with no known risk factors for TB
How do you treat active TB?
Rifampicin - 6m
Isoniazid - 6m
pyrazinamide - 2m
ethambutol - 2m
What are the side effects for rifampicin?
Red orange bodily fluids
GI side effects
rash
cytopenias
What are the side effects for Isoniazid?
Neurotoxicity
hepatotoxicity
What are the side effects for Pyrazinamide?
Hepatotoxicity
hyperuricemia
What are the side effects for ethambutol?
Optic neuropathy
What is interstitial lung disease?
An umbrella term for a number of diseases which cause scarring and fibrosis of the intercession a can be idiopathic or secondary.
What is idiopathic pulmonary fibrosis?
The most common primary – idiopathic cause of interstitial lung disease however it is still rare. It is a chronic and life-threatening disease occurring over the course of years causing the formation of scar tissue in the lungs and progressive shortness of breath.
What Are characteristic features on a history of idiopathic pulmonary fibrosis?
Progressive shortness of breath
weight loss
fever
malaise
occurring in patients who are older, smokers, male, have a positive family Hx
In idiopathic pulmonary fibrosis what can be heard in the lungs on physical examination?
Crackles
What investigations are required for idiopathic pulmonary fibrosis?
pulmonary function tests Chest x-ray CT ANA (antipsychotic citruttinated peptide and myosistitis panel show a collagen cause)
What is a characteristic feature found on CT to do with idiopathic pulmonary fibrosis?
Honeycomb lung
What is the management of idiopathic pulmonary fibrosis?
pulmonary rehabilitation Anti-fibrinolytic therapy - pirfenidone stopping smoking PPI (relationship is unknown) ambulatory oxygen if indicated by hypoxia
Lung transplant
What management is required in the acute exacerbation of idiopathic pulmonary fibrosis?
Admitted to hospital
oxygen
prednisolone high dose
you can also give cytotoxic therapy
What is sarcoidosis?
A secondary cause of interstitial lung disease.
A chronic granulomatous disorder of unknown aetiology affecting lungs, lymph most commonly but is a multi system disease, by creating non-sating granulomas
When does sarcoidosis usually present?
Aged 30 to 50 years
What is the presentation of sarcoidosis?
Usually pulmonary:
shortness of breath, non-productive cough, wheezing
can be renal:
hypercalcaemia symptoms, hypercalceuria, renal insufficiency
ocular:
pain and redness and I can cause uveitis, keratoconjunctivitis, glaucoma, cataracts
neurological:
seizures, deficits, cranial nerve palsies, peripheral neuropathy, hypothalamic or pituitary lesions,
cutaneous:
erythematous
How would you diagnose sarcoidosis?
Chest x-ray and lungs usually shows adenopathy and fibrosis
pulmonary function tests
biopsy shows non-key sating granulomas
liver enzymes AST, ALC: elevated
hypercalcaemia
two by killing PPD test: negative
urea and creatinine elevated if renal involvement
What is the management of Pulmonary sarcoidosis?
Do not manage until symptomatic
oral or inhaled corticosteroids
oral or inhaled corticosteroids plus adjunct cytotoxic drugs plus oxygen
at the end stage lung transplant is needed
How would you manage cutaneous sarcoidosis?
Topical or PO corticosteroids
secondary: cytotoxic
How would you manage ocular sarcoidosis?
If anterior uveitis or optic neuritis present:
topical corticosteroids moving on to oral corticosteroids
caution in glaucoma
what is rheumatic lung?
A recognised complication of rheumatoid arthritis and in some cases can be caused by the treatment of rheumatoid arthritis (methotrexate)
How do you manage rheumatic lung?
Either treat the rheumatic arthritis or discontinue treatment if treatment is because
How does SLE cause interstitial lung disease?
Can cause pleural inflammationAnd various other lung disorders
what is asbestosis?
Interstitial fibrosis of the long occurring from exposure to asbestos rather than a connective tissue disorder
How does asbestos cause lung disease?
Fibres cause plaques, pleural thickening, and benign pleural effusions.
How long after asbestos exposure does asbestosis present?
What is the symptoms of asbestosis?
After 10 years
shortness of breath (usually on exertion)
cough
crackles in the chest
What investigations are there for asbestosis?
CT /XR
pulmonary function tests showing restrictive changes
What would you find on CT for asbestosis?
showing lower zone linear fibrosis (at the start)
more diffuse fibrosis later on
finally pleural thickening
What is a treatment for asbestosis?
Smoking cessation
early antibiotics if there is a lung infection
if there is an obstructive pattern (usually as a smoker to) start COPD management
pulmonary rehab and O2 are adjunct to treatment
pleural decortication or lung transplant is second line
What is pneumoconiosis?
A group of interstitial lung diseases mostly of occupational origins caused by inhalation of mineral or metal dust
usually occupations which have exposure to silica coal or beryllium
what is the presentation of pneumoconiosis
Shortness of breath and cough later progressing to findings on examination of the chest such as crackles
What is seen on x-ray for pneumoconiosis?
Hundreds of rounded opacities seen in upper zones in silicosis and co-workers lungs which then join up Forming egg shell calcifications
What test can be done if you suspect beryllium exposure?
The really lymphocyte proliferation test
How do you manage chronic pneumoconiosis?
Remove from exposure smoking station corticosteroids pulmonary rehab supplementary O2 if hypoxic COPD management if obstructive pattern
advise on entitlement compensation!
How do you manage acute disease of pneumoconiosis?
Silicosis : lung lavage
berylliosis: corticosteroids
what is pulmonary hypertension?
An increase in arterial blood pressure in the lungs Which can lead to right-sided heart failure
What causes pulmonary hypertension?
Left sided heart failure
chronic lung disorders
portal hypertension
Blood clots
What are the features of pulmonary hypertension?
Shortness of breath chest pain peripheral oedema syncope tachycardia
What other characteristic lung findings of pulmonary hypertension on chest x-ray?
Increased pulmonary vascular markings
how to manage pulmonary hypertension?
Calcium channel blocker
diuretics
anticoagulants
digoxin
What is a pleural effusion?
A collection of fluid between parietal wall and visceral surfaces of the thorax, occurring when too much fluid is produced or too little fluid is removed
What are the two categories of pleural effusion?
Exudative: local factors altered ie inflammation
Transudative: systemic factors altered eg LSHF. RSHS, Cihrossis
What can cause pleural effusion?
Local infection such as pneumonia
malignancy
recent cardiac surgery
congestive heart failure (both sided)
A patient presents with dysnopea, dullness and percussion, 30 chest pain, diminished breath sounds and non-productive cough what are these symptoms characteristic of?
pleural effusion
What investigations would you want to perform in a pleural effusion?
Chest x-ray
ultrasound of the pleural space
finding cause: pleural fluid culture: effusion or empyema? pleural fluid cytology (?malignancy) pleural fluid analysis infection markers(FBC, CRP, ESR) heart failure markers (NT pro BNP)
What Is an empyema
defined as a collection of pus in the pleural cavity, gram-positive, or culture from the pleural fluid. Empyema is usually associated with pneumonia
What finding would you find on chest x-ray for pleural effusion?
blunting of costo phrenic angles
What is the management of the pleural effusion?
Underlying cause
diuretics in congestive heart failure
antibiotics in infection
thoracoscentesis in recurrent for malignancy
what is a pneumothorax?
An accumulation of in the pleural space
What are the types of pneumothorax?
open ( simple)
closed
tension
What is an open pneumothorax?
Open pneumothorax is when there is a hole between the outside and the pleural cavity meaning that the pressure outside inside the cavity is the same
meaning air from outside the body moves into the pleural space and can move back out
What is a closed pneumothorax?
The pressure in the pleural cavity is less than external pressure meaning air from the lung moves into the pleural space and can move back in
What is a tension pneumothorax?
The pressure of the pleural cavity is greater than the atmospheric pressure meaning that gets sucked into the pleural space and cannot leave
What is the presentation of a pneumothorax?
Unless presenting in an acute situation it can be asymptomatic and insidious
in acute situations also their pneumothorax there is:
tachycardia
decreased breath sounds unilaterally
hyper- resonant unilaterally
hyperaemia hypotension
tracheal deviation is a late sign in tension pneumothorax and is close to death
what is the investigation of a pneumothorax?
any situation all acute trauma getting multiple IV lines is important. assessing the front and back of the patient. Getting a fast scan.
a chest x-ray or ultrasound can show a pneumothorax
What is the management of tension pneumothorax
Cannula needle decompression - 2nd intercostal mid clavicular unless if large pt then 5h clavicular space mid axillary line
thoracostomy and chest drain.
O2 therapy
what is the management of an open pneumothorax?
A three sided closed because creating a valve
what is the management of Simple pneumothorax that is small?
02 an observation
What is the management of a simple pneumothorax that is large?
thoracotomy and chest drain
What is the management of a heamothorax?
chest drain and thoracotostomy + blood
What is flail chestAnd how is it managed?
When there are multiple broken ribs that when you inspire and expire was further damage to the lungs.
managed with CPAP until surgery as possible and then surgical management
What is a small cell lung cancer?
An extremely aggressive malignancy which usually at the time of presentation has distant metastases.
A malignant epithelial tumour arising from the lower respiratory tract/
What is the main risk factor for small-cell lung cancer?
smoking
What is the presentation lung cancer?
cough dysnopea Shortness of breath haemoptysis chest pain generalised red flags
What is the first line investigation in small cell lung cancer?
and what does it show?
Chest x-ray
a central mass, hilar lymphadenopathy pleural effusions
If you suspect the small-cell lung cancer on chest x-ray what following investigations should you take?
CT – chest, liver, adrenal glands
sputum cytology
biopsy
What is non-small cell lung cancer?
A group of adenocarcinomas and squamous cell carcinomas and large cell epithelial cell tumours
Which lung cancer is most common non-small cell or small cell?
non Small-cell - 80% of all lung cancers
what is mesothelioma?
An aggressive epithelial neoplasm arising from the lining of the lungs ( also can arise from abdomen, accordion or tunica vaginalis)
What is the major risk factor for mesothelioma?
Asbestos
What is the presentation of mesothelioma?
If in the lungs shortness of breath, cough, chest pain
if in the abdomen: bloating, abdominal pain, bowel changes, lack of appetite
How can you diagnose mesothelioma?
CT
Biopsy
What is a pulmonary embolism?
A blood clot in the pulmonary arteries
What is Virchows Triad?
the three factors which predispose someone to thrombosis:
hyper coagulability
trauma to the endothelium
venous stasis
What is the presentation of a pulmonary embolism?
pyrexia tachycardic tachyopneic SOB pleuritic chest pain cough and haemoptysis recent DVT sx – oedema, redness, tenderness, unilateral, thrombophlobitis low O2 sats
What investigation is diagnostic for a pulmonary embolism?
CTPA
What investigations would you like to perform if you are suspecting a pulmonary embolism but want to exclude other differential diagnoses?
ECG – r sided strain/ r axis deviation and rule out coronary syndrome or pericarditis (saddle shaped st elevation and PR depression)
XCR – shows any effusions, pulmonary infarcts (rare) and regional oedema, rules out consolidations etc
ABG – acidosis in infections from hypoxia
FBC – infections
Cardiac troponin – MI but also ++ in massive PE
Echo – pericarditis, IE, efffusion
What tests can aid in the diagnosis of pulmonary embolism?
D Dimer
Leg USS + doppler : ? DVT
Coag studies
What is a treatment for pulmonary embolism is haemodynamically unstable ?
Fluid resus
Thrombolysis - altepase
warfarin or LMWH
continue anticoagulants for 3months
What is a treatment for pulmonary embolism is haemodynamically stable ?
anticoagulants (LMWH/ RIvaroxiban/Warfrin)
continue for 3 months
What is a pulmonary infarct?
a rare consequence of a Pulmonary embolus where there is localised necrosis of lung tissue due to decreased arterial blood supply
What is the management of pulmonary infarct?
fibrinolysis or surgical/catheter removal
