Respiratory Flashcards
Define Asthma
Chronic inflammatory disease of airways characterised by
1) Bronchial hyperresponsiveness to stimuli (t1)
2) Reversible and variable airflow obstruction
3) Inflammation of bronchi
Pathophysiology of asthma
- type 1 igE mediated hypersensitivity reaction to stimuli
- igE on mast cells activated -> cytokine ->
- Early phase: smooth muscle contraction, mucus production, bv permeability
- Late phase: Inflammation
- Long term: airway remodelling, BM thicken, collagen deposit = irreversible airflow restriction
Epidemiology of asthma
More common in boys as children and girls as adults
Likely larger genetic role as children and env as adults
Presentation of asthma and features of history
Wheeze
SOB
Chest tight
Cough
Diurnal variation (worse at night and early morning)
Triggered by or made worse by something
Variable, recurrent and frequent symptoms
History of allergies
Smoker or around them
Family history of atopy or asthma
Asthma :aetiology precipitating factors
genetic and environmental component (atopic triad)
hygiene hypothesis
2 types of triggers: inducer + provoke
INDUCER enhance inflammatory response (physical antigen). Intrinsic asthma, children more
- allergens, viral, occupation exposure
PROVOKER enhance bronchospasm. Extrinsic asthma
- excercise, cold air, emotions, drugs (NSAID/aspirin, beta blocker)
Clinical signs of asthma on examination
Expiratory wheeze (polyphonic)
Hyperinflated chest
May see pec/SCM hypertrophy in poor managed
NB Severe asthma = no wheeze, silent chest
Investigations for asthma
Peak flow- show variable airflow limitation
Spirometry - show obstructive, decreased FEV1 to predicted
CXR + FBC to rule out other pathology
Stepwise management of asthma and SE of BA, ICS
- Remove triggers, stop smoking, lose weight
- Step 1 - PRN ICS + SABA or PRN ICS(budesonide) + LABA(formoterol)
- Step 2 - latter of step 1 or daily ICS + PRN SABA
- Step 3 - daily ICS + daily LABA(salmeterol, formoterol) + PRN SABA or higher dose ICS+PRN SABA
- Step 4 - add oral corticosteroids like prednisolone
- Beclametasone = Clenil, Qvar
- Budesonide = Pulmicort
- SE: sore throat/oral thrush, osteoporsis high dose
Beta agonists - tachy, hypOK
- Target infalmm- Leukotriene receptor antagonist
- Oral monteleukast
- CI in pregnancy and liver disease
- Add on, can be combined w 3 if 4 fails
- SE: hypersensitivity, Gi SE
Define acute severe asthma
Any one of:
- Cannot complete sentences
- HR >= 110
- RR >=25
- PEF <50% of predicted
Life threatening:
- silent chest, exhaustion, confused
- Sp02 <92% Pa02< 8
- hypotensive
- PEF <33%
Management of asthma attack
- 15L non rebreathe (A-> E assess)
- Nebulised salbutamol or terbutiline
- IV prednisolone
- nebulised iprotroprium bromide (short antimuscarinic)
?. MgS04 aminophylline mechanical vent
aim: sats > 94%
Define COPD
Chronic, partly irreversible, progressive, airway obstruction due to airway and parenchyma damage
may be accompanied by hypersensitivity
encompasses:
- Chronic bronchitis
- Emphysema
Risk factors for COPD
- Smoking (majority)
- Occupational exposure- coal, silica, dust, textile
- Biomass/coal/fuels internationally
- Alpha-1 antitrypsin deficiency
Define chronic bronchitis + pathophysiology
Chronic bronchitis:
- chronic productive cough for 3 months each in 2 consecutive years with no other explanation for cough
Path:
inflammation, mucus hypersecretion + airway narrowing
Define emphysema
Abnormal permanent dilation of airways distal to terminal bronchioles + destruction of their walls without obvious fibrosis
How does smoking -> COPD (pathophysiology)
toxin -> macrophage/cd8 lymphocyte recruitment -> neutrophil response -> protease activation
protease -> mucus hypersecretion in chronic bronchitis or alveolar destruction in emphysema
alpha 1 antitrypsin usually inhibits neutrophil protease activity
Presentation of COPD px
- SOB, worse on exertion
- Chronic productive cough (quantify)
- Expiratory wheeze
- Weight loss
- May have astham overlap - diurnal variation
- Chronic hypoxoemic, shut down pul circ -> RHF signs raised JVP, peripheral oedema
- Peripheral cyanosis, barrel chest
Investigation for COPD
- spirometry FEV1/ FVC <0.7
- Severity = how reduced their FEV is
Also need to do:
Bedside sats
FBC (elevated hb and rbc)
CXR
ABG
ECG (RH strain)
CT - distribution of emphysema may indicated a1antitrypsin if > at bases
Management of COPD
conservative = smoking cessation, vaccines (flu, pneumococcal), pulmonary rehab,reduce occupation exposure
FIRST: SABA(salbutamol) or SAMA (iprotroprium)
then ? asthma
if no asthma then LABA (salmeterol, formoterol) + LAMA (tiotropium) + SABA - SAMA if on before
if asthma + ICS
can also try:
- oral PDE inhibitor, bronchodilator theophyline
- ? prophylactic abx and mucolytics
- ? LTOT
-? surgery
Management of COPD exacerbation
- oxygen (84-92)
- increase bronchodilator frequency
- Add oral prednisolone
- abx - amoxicillin, clarithromycin, doxycycline
- phsyio (sputum)
MAY need NIV for pxs in T2RF
Smoking cessation devices
lots of forms of NRT - lozynges, patches, vape
or prescribed drugs:
- Bupropion (zyban)- antidepressant which can help smoking cessation, CI: seizures
- Varenicline (champix) NRagonist, not for px with psychiatric problems
Define bronchiectasis
Abnormal and permanent dilation of airways leading to accumulation of secretions and secondary infection/inflammation
Causes of bronchiectasis
- Cystic fibrosis
- post infection
- idiopathic
Presentation of px with bronchiectasis
Chronic productive cough copious amounts
recurrent chest infections
may have haemoptysis, sob, wheeze
Investigating for bronchiectasis
HRCT is gold standard, will show dilation and wall thickening- signet ring
Sputum culture on exacerbation
CXR may be helpful
Management of bronchiectasis
- Physiotherapy
- smoking cessation
- vaccines
medical:
- abx
- bronchodilators/corticosteroids
- neb saline
- NIV
- may have surgical
Lung cancer risk factors
- SMOKING
- occupation exposure
- air pollution
- radiation
- idiopathic + post infectious pulmonary fibrosis
- rarely genetic
- can sporadically occur in young females
Types of lung cancer
4 types of primary bronchial carcinomas = 95% of all lung cancer. first 3 are NSCC
- Adenocarcinoma
- Squamous cell carcinoma
- Large cell carinoma (rarest)
- Small cell (oat) carcinoma
- Carcinoid tumour
Types of lung cancer other than bronchial
- Malignant mesothelioma of pleura
- Secondary to mets
Adenocarcinoma (most common NSCC)
- cancer of larger airway
- peripheral solid mass, may appear ground glass so appear as infection
- Arise from neuroendocrine cells so can -> paraneoplastic syndromes
- Most strongly assd with smoking
- Highly aggressive, poor prognosis, present with mets
- untreated median survival 6 weeks
Squamous cell carcinoma (NSCC)
- Central cavitating mass can be confused w abscess
- Used to be most common
-
most strongly assd with smoking
*
Presentation of px with lung cancer
- Persistent cough (>6w)
- Haemoptysis
- SOB
- Chest
- Unintentional weight loss
- Fatigue
- Lymphadenopathy
May present with signs of paraneoplastic syndrome
Cushing XS ACTH (esp oat)
SiADH (oat)
Hypercalcaemia (SCC)
Clubbing
Diagnosis for lung cancer
Tissue sampling (many methods depending on frailty and location) and then immunohistochemistry
Small cell carcinoma
Only 10% of lung cancers
strong smoking asscn
- massive mediastinal lymphadenopathy
- may cause SVCO
- Most present at stage 4, poor prognosis bc nearly always mets
Carcinoid tumour
- Very rare type of lung cancer
- no/little asscn with smoking
- well defined golf balls on x ray
- majority are localised therefore curable
Management of lung cancer
Local: radio, surgery + adjuvant chemo if adv on surg
Stage 4: palliative chemo, immuno, targeted molecular, maybe radio
Molecular targeted therapy target mutations in normal molecular processes that have enabled tumour growth
Immunotherapy targets tumours ability to evade T cell destruction
Mesothelioma
Tumour of pleura
NB rare cause, tumours of pleura are usually emtastatic adenocarcinoma
Presnets with SOB and chest pain!
asbestos exposure
poor prognosis
palliative chemo/radio
Define Pneumonia
Infection of lung parenchyma
Usually caused by bacterial organism:
streptococcocus pneumoniae (pneumococcus)
Can be lobar or broncho
Presentation of px with pneumonia
- Fever
- Productive cough
- SOB
- Pleuritic chest pain
- Confusion, weakness ,malaise esp elderly
May present with septic shock, organ dysfunction
Precipitating factors for pneumonia
- Underlying lung disease
- smoking
- alcohol abuse
- immunosuppresion
- any chronic illness
Organisms causing pneumonia and relevant history q
Bacterial:
- Pneumococcus (most common)
- Haemophilus influenza
- Chlamydia psittacosis (BIRDS) may assd rash, hep
- Coxiella burnetti (farm animals)
- Legionella (hotels etc) assd w GI problem, multilobar
- mTB (alcohol abuse)
- mTB, staph aures (IVDA)
- Mycoplasma (young, headache, malaise, cough, rashes) reticular opacity, fine
Many other viral and fungal causes too
Diagnosing/investigating for pneumonia
Bedside: blood culture, sputum culture
urinary antigen test for pneumococcal/legionella cause
serology and throat swab for mycoplasmic cause
Imaging: CXR (changes lag)
Assessing severity of pneumonia
CURB-65 helps assess mortality risk
C: confusion
U: urea
R: resp rate
B: BP hypotensive
65 age
Management of pneumonia
If septic -> sepsis 6, wil prob need ox and fluid
Pneumococcal or haemophilus : Benzylpenicillin/amoxicillin or clarithromycin for pen allergy
Legionella: Levofloxacin/macrolide
Mycoplasma: clarithromycin
ie if really unwell: levofloxacin/clarithromycin may be +
Why does HAP happen and how is it managed
Px severely ill stay > 1w -> change normal flora and aspirate
Early: co-amoxiclav
Late: Piperacillin-tazobactam
Aspiration pneumonia cause consequence and management
Impaired swallow/gag reflex due to stroke, dementia, MND
Aspirate saliva, gastric contents (GNA), food
tends to go down R bronchus: shorter and steep
Leads to infection and lobar bronchiectasis
Manage: co-amoxiclav and SALT
Definition and types of pneumothorax
Air in pleural space leading to lung deflation.
1) Primary (normal lung)
2) Secondary (underlying lung disease)
3) Tension
Causes of pneumothoraces by type
Primary Spontaneous Pneumothorax
- RF: men, marfans, 30-40, cigs, cannabis
- Path: ? maybe rupture of apical bleb/bullae
Secondary Spontaneous Pneumothorax
- RF: lung disease eg COPD, Asthma, ILD
Tension Pneumothorax
- Blunt trauma nb can -> compress mediastinum, hypotension -> cardiac arrest
Presentation of pneumothorax
ACUTE onset of SOB, pleuritic chest pain (PE same)
Tension: assd raised JVP, hypotension
Inv pneumothoraces
CXR
dont wait for CXR if high suspicion of tension
Management of pneumothoraces
PSP: Depends on px symptoms, size of pneumo, age (old treat same as SSP)
Asymptomatic + small = discharge
Symptomatic + large = cannula 2nd ICS MCL, may need to chest drain
SSP: depends on size
Either discharge, attempt aspiration or drain, drain and 15L oxygen
may have underwater seal drainage system
Tension: 15L ox, large cannula 2nd iCS MCL once stable cxr and drain
Define Pleural effusion
Accumulation of fluid in pleural space
Two types of pleural effusion and causes
- Transudate
- Clear
- Low protein
- Failures (Heart, Liver, Renal)
- Hypo-albuminemia
- Exudate
- cloudy
- high protein
- Infection (paraneumonic, empyema, TB)
- Malignancy
- PE
- Inflammatory
Presentation of px with pleural effusion
SOB, pleuritic chest pain, cough + symptoms reld to cause
Diagnostic investigation of pleural effusion
CXR + USS to confirm presence
USS may show loculated effusion = empyema
CT not routinely done
Pleural tap/fluid aspiration/thoracentesis under USS guide
- Send sample for biochem, microbiology and cytology
- Protein <25 trans, >35 ex. Inbetween use lights criteria
*
Management of transudate pleural effusion
Treat underlying cause
Management of exudate pleural effusion where cause is infection (para-pneumonic)
Parapneumonic - effusion is assd with underlying lung infection
FLUID ITSELF IS STERILE SO NO NEED TO DRAIN
Treat with abx long course
may therapeutic drain if px symptom bad
Management of exudate pleurla effusion when cause is infection (empyema)
URGENT DRAIN because fluid is infectious
long course abx
consider surgery/ct thorax
Management of exudate pleural effusion when cause is infection (TB)
Likely that pleural tap results inconclusive so need to do ct thorax and PLEURAL biopsy
Dont need to drain unless for px
long course tb treatment
Management of exudate pleural effusion when cause is malignancy
May be primary pleural malignancy or mets
Pleural tap may not show + cytology but do CT TAP (mets)
if thats inconclusive or suggestive of primary pleural malignancy do a pleural biopsy
treat malignancy, therapeutic tap, may need to do pleurodesis (stick) or catheter if recurring (common to)
Define a pulmonary embolism
Embolus from thrombus usually of deep veins in leg or pelvis, that lodges in pulmonary arteries
RF for PE
- Recent surgery
- History of VTE
- Oral contraceptive
- Pregnancy
- Coag disorders
- Malignancy
- Obesity
- Age > 60
- long haul travel
Presentation of PE
- sudden onset SOB, inc RR
- Pleuritic Chest pain
- haemoptysis
- may have cough
- calf pain DVT signs inconsistent
MASSIVE PE (hypotensive)
- RH signs (raised JVP, oedema)
- Hypotensive, shock
- Syncope
MAY have chronic - lots of little ones
- gradual dyspnoea -> pul hypertension
Investigating PE
- Wells score for PE
- <=4 do a D dimer
- if D dimer negative, rule out PE
- all else -> CTPA or V/Q but not specific
Management of a PE
- If massive PE: clot buster (alteplase)
- Otherwise: anticoag (fondaparineux or LMWH)
- Then may have longterm DOAC (-ban) or VKA (warfarin)
Define TB
A curable bacterial infection caused by mycobacterium tuberculosis that is contageous when effcting lungs.
Results in granulomatous inflammation
Pathophysiology of TB
Macrophages engulf enhaled TB
These fuse -> Giant cells
Granuloma = Langhan giant cells, macrophages and central caseous necrosis containing some free TB
Calcified granuloma = Ghon focus on XR (typically upper lobe)
Ghon complex = focus + lymph node
Types of TB
Primary - first hit in children, immunosuppressed individuals -> active infection
Secondary - reactivation of latent infection due to decline in health/immunity
Can have latent for life
Latent tb screening
Tuberculin skin test -> positive = type 4 cell mediated hypersensitivity reaction
IGRA -> interferon gamma released to blood sample
BUT these can be positive for both active and latent tb so history needed
Presentation of TB
- Fever
- Weight Loss + fatigue
- Night sweats
May also get cough, haemoptysis, abdo pain, headache, back pain bc tb can effect everywhere
nb dd cancer
Miliary TB
Millet seed pattern throughout lung parenchyma
Signifies systemic dissemination of TB
Causes of granulomatous inflammation other than TB
- Sarcoidosis
- Crohns
- GPA (vasculitis)
- Infection
- Foreign body
Management of TB and SE
6 months NB 9-24 if drug resistant
2 months RIPE
Rifampicin (orange)
Isoniazid (peripheral neuropathy)
Pyrazinamide (hepattox)
Ethambutol (eyes)
4 months RI
How is TB diagnosed
Auramine stain on sputum. fluorescent yellow
Ziehl Neelson stain requires culture. shows up red on blue, can see morphology
solid culture (most sensitive)
QUICKER:
TB PCR straight from sputum + test rifampicin resistance
New dev: WGS for drug sensitivity
What is sore throat and the main infectious causes
Pharyngitis +- tonsilitis
Mostly viral
important bac cause: Group A strep
Group A Strep Pharyngitis inv, management and complications
gram + bacterial cause of sore throat
NB not your typical cough, rhinorrhoea, sore throat- viral
Throat swab-> blood culture-> beta haemolysis, complete
Centor criteria indicates whether to start abx for sore throat, may involve doing a rapid antigen test if ambiguous
Manage: oral penicillin V for 10 days, clarithromycin if allergy
Consequence: scarlet fever, quinsy, rheum fever and post infection glomerulonephritis
What is diptheria, complications and mangement
gram + aerobic bacterial toxin-mediated that rarely causes pharyngitis/tonsilitis in UK
adherent to membrane -> obstruction
toxin can also -> myocarditis and neuropathy
Manage: penicillin/erythromycin, antitoxin, secure airway
What is glandular fever/infectious mononucleosis, presentation, diagnosis, management
mainly ebv mediated cause of pharyngitis in Uk
Presents: malaise,fever, sore throat, lymphadenopathy, splenomegaly, rash if given amoxicillin
Diagnosis: Serology (igM, igG, EBNA)
Treat symptoms and avoid contact sports for 6 weeks -> spleen rupture
Organisms causing sinusitis/otitis media
same organisms that cause URTi
- Viruses (majority)- RSV, rhinovirus
- Bacteria - pneumococcus, haemophilus influenza
Presentation of otitis media + sinusitis
Acute, usually young children (shorter eustachian tube)
Pain, malaise, fever, coryza
hearing issues, dizziness
Can -> sinusitis
nasal congestion/smell , face pressure ( can be referred to forehead, eyes, upper jaw, teeth)
Management of OM/sinusitis and complications of sinusitis
Decongestants, rarely abx
Grommet for recurrent OM
Complications of sinusitis:
Mastoiditis
Meningitis (pneumococcal)
Intracranial abscess
What is epiglottitis, cause, presentation, diagnosis, management
Acute inflammation of epiglottis
Rare because vaccinate against
Cause: bac haemophilus influenza type B
Present: dysphonia, dysphagia, drooling, distress
Diagnose: blood culture NOT swab
Manage: fix airway, tracheostomy + IV abx (ceftriaxone)
What is whooping cough, cause, presentation, diagnosis, management
Highly infectious bacterial infection caused by Bordetella Pertussis. rare = vaccine
Present:
- 2 weeks: standard virus symptoms, coryza BUT highly infectious
- 2-6 weeks: intense cough
- chronic cough
Diagnose: PCR swab
Manage: a macrolide abx
Consequence: fail thrive, apnoea, pneumothorax, subcut emphysema, brain damage
What is croup, cause, presentation, diagnosis, management
UR/LRTi - larynx/trachea caused by viruses eg RSV
Present: young children esp 18months, barking cough/seal, hypoxic, tachypnoeic
Diagnosis: clinical
NB dont forget epiglottis, bac tracheitis and aspiration in kids
Manage: dexamethasone, paracetamol, ox
usually self limiting
Flu - causes, symptoms, diagnosis, complications, management
Lots of viruses: RSV, coronas, para/influenza,adeno
Type A and B (human only, cant cause pandemic) HN
Symptoms: fever, malaise, myalgia, headache, coryza, cough, sore throat
Diagnosis: Swab and PCR
complications: viral pneumonia or secondary bac pneumonia
Manage: neuraminidase inhibitors, oseltamavir, zanamivir (less resistance)
What is bronchiolitis, cause, pres, diagnosis + outcomes
Infection of smaller airways, usually in children (6m). Most common cause of adm <1yr
Causes: viruses eg RSV
Presentation: snuffles, fever, mild cough, worse @ night, difficulty feeding. can -> resp distress (admission)
Diagnose: PCR swab
outcomes: recovery 10 days, mortality, secondary bac pneumonia
Define exacerbation of COPD
change in baseline in 2/3 of:
- Volume of sputum
- character of sputum
- breathlessness/wheeze
Organisms causing acute exac of COPD
Bacterial:
- pneumococcus
- haemophilus
- moraxella catarrhalis
- ecoli, klebsiella
Viral:
- RSV/rhino/flu/adeno
Non infective
Management of COPD exac
Bronchodilation: salbutamol + ipratropium
Steroid: prednisalone
May need abx
Interstitial lung disease definition, causes, presentation and tx
scarring at interstitium
Causes:
1) idiopathic
2) infection
3) secondary to exposure
Present with SOB
Treat steroids but poor prognosis
