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CC2 > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Define Asthma

A

Chronic inflammatory disease of airways characterised by

1) Bronchial hyperresponsiveness to stimuli (t1)
2) Reversible and variable airflow obstruction
3) Inflammation of bronchi

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2
Q

Pathophysiology of asthma

A
  • 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
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3
Q

Epidemiology of asthma

A

More common in boys as children and girls as adults

Likely larger genetic role as children and env as adults

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4
Q

Presentation of asthma and features of history

A

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

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5
Q

Asthma :aetiology precipitating factors

A

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)
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6
Q

Clinical signs of asthma on examination

A

Expiratory wheeze (polyphonic)

Hyperinflated chest

May see pec/SCM hypertrophy in poor managed

NB Severe asthma = no wheeze, silent chest

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7
Q

Investigations for asthma

A

Peak flow- show variable airflow limitation

Spirometry - show obstructive, decreased FEV1 to predicted

CXR + FBC to rule out other pathology

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8
Q

Stepwise management of asthma and SE of BA, ICS

A
  1. Remove triggers, stop smoking, lose weight
  2. Step 1 - PRN ICS + SABA or PRN ICS(budesonide) + LABA(formoterol)
  3. Step 2 - latter of step 1 or daily ICS + PRN SABA
  4. Step 3 - daily ICS + daily LABA(salmeterol, formoterol) + PRN SABA or higher dose ICS+PRN SABA
  5. Step 4 - add oral corticosteroids like prednisolone
  • Beclametasone = Clenil, Qvar
  • Budesonide = Pulmicort
  • SE: sore throat/oral thrush, osteoporsis high dose

Beta agonists - tachy, hypOK

  1. 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
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9
Q

Define acute severe asthma

A

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%
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10
Q

Management of asthma attack

A
  1. 15L non rebreathe (A-> E assess)
  2. Nebulised salbutamol or terbutiline
  3. IV prednisolone
  4. nebulised iprotroprium bromide (short antimuscarinic)

?. MgS04 aminophylline mechanical vent

aim: sats > 94%

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11
Q

Define COPD

A

Chronic, partly irreversible, progressive, airway obstruction due to airway and parenchyma damage

may be accompanied by hypersensitivity

encompasses:

  1. Chronic bronchitis
  2. Emphysema
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12
Q

Risk factors for COPD

A
  1. Smoking (majority)
  2. Occupational exposure- coal, silica, dust, textile
  3. Biomass/coal/fuels internationally
  4. Alpha-1 antitrypsin deficiency
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13
Q

Define chronic bronchitis + pathophysiology

A

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

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14
Q

Define emphysema

A

Abnormal permanent dilation of airways distal to terminal bronchioles + destruction of their walls without obvious fibrosis

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15
Q

How does smoking -> COPD (pathophysiology)

A

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

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16
Q

Presentation of COPD px

A
  1. SOB, worse on exertion
  2. Chronic productive cough (quantify)
  3. Expiratory wheeze
  4. Weight loss
  5. May have astham overlap - diurnal variation
  6. Chronic hypoxoemic, shut down pul circ -> RHF signs raised JVP, peripheral oedema
  7. Peripheral cyanosis, barrel chest
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17
Q

Investigation for COPD

A
  • 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

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18
Q

Management of COPD

A

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

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19
Q

Management of COPD exacerbation

A
  • oxygen (84-92)
  • increase bronchodilator frequency
  • Add oral prednisolone
  • abx - amoxicillin, clarithromycin, doxycycline
  • phsyio (sputum)

MAY need NIV for pxs in T2RF

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20
Q

Smoking cessation devices

A

lots of forms of NRT - lozynges, patches, vape

or prescribed drugs:

  1. Bupropion (zyban)- antidepressant which can help smoking cessation, CI: seizures
  2. Varenicline (champix) NRagonist, not for px with psychiatric problems
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21
Q

Define bronchiectasis

A

Abnormal and permanent dilation of airways leading to accumulation of secretions and secondary infection/inflammation

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22
Q

Causes of bronchiectasis

A
  • Cystic fibrosis
  • post infection
  • idiopathic
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23
Q

Presentation of px with bronchiectasis

A

Chronic productive cough copious amounts

recurrent chest infections

may have haemoptysis, sob, wheeze

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24
Q

Investigating for bronchiectasis

A

HRCT is gold standard, will show dilation and wall thickening- signet ring

Sputum culture on exacerbation

CXR may be helpful

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25
Q

Management of bronchiectasis

A
  • Physiotherapy
  • smoking cessation
  • vaccines

medical:

  • abx
  • bronchodilators/corticosteroids
  • neb saline
  • NIV
  • may have surgical
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26
Q

Lung cancer risk factors

A
  1. SMOKING
  2. occupation exposure
  3. air pollution
  4. radiation
  5. idiopathic + post infectious pulmonary fibrosis
  6. rarely genetic
  7. can sporadically occur in young females
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27
Q

Types of lung cancer

A

4 types of primary bronchial carcinomas = 95% of all lung cancer. first 3 are NSCC

  1. Adenocarcinoma
  2. Squamous cell carcinoma
  3. Large cell carinoma (rarest)
  4. Small cell (oat) carcinoma
  5. Carcinoid tumour
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28
Q

Types of lung cancer other than bronchial

A
  1. Malignant mesothelioma of pleura
  2. Secondary to mets
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29
Q

Adenocarcinoma (most common NSCC)

A
  • 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
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30
Q

Squamous cell carcinoma (NSCC)

A
  • Central cavitating mass can be confused w abscess
  • Used to be most common
  • most strongly assd with smoking
    *
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31
Q

Presentation of px with lung cancer

A
  • 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

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32
Q

Diagnosis for lung cancer

A

Tissue sampling (many methods depending on frailty and location) and then immunohistochemistry

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33
Q

Small cell carcinoma

A

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
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34
Q

Carcinoid tumour

A
  • Very rare type of lung cancer
  • no/little asscn with smoking
  • well defined golf balls on x ray
  • majority are localised therefore curable
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35
Q

Management of lung cancer

A

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

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36
Q

Mesothelioma

A

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

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37
Q

Define Pneumonia

A

Infection of lung parenchyma

Usually caused by bacterial organism:

streptococcocus pneumoniae (pneumococcus)

Can be lobar or broncho

38
Q

Presentation of px with pneumonia

A
  • Fever
  • Productive cough
  • SOB
  • Pleuritic chest pain
  • Confusion, weakness ,malaise esp elderly

May present with septic shock, organ dysfunction

39
Q

Precipitating factors for pneumonia

A
  1. Underlying lung disease
  2. smoking
  3. alcohol abuse
  4. immunosuppresion
  5. any chronic illness
40
Q

Organisms causing pneumonia and relevant history q

A

Bacterial:

  1. Pneumococcus (most common)
  2. Haemophilus influenza
  3. Chlamydia psittacosis (BIRDS) may assd rash, hep
  4. Coxiella burnetti (farm animals)
  5. Legionella (hotels etc) assd w GI problem, multilobar
  6. mTB (alcohol abuse)
  7. mTB, staph aures (IVDA)
  8. Mycoplasma (young, headache, malaise, cough, rashes) reticular opacity, fine

Many other viral and fungal causes too

41
Q

Diagnosing/investigating for pneumonia

A

Bedside: blood culture, sputum culture

urinary antigen test for pneumococcal/legionella cause

serology and throat swab for mycoplasmic cause

Imaging: CXR (changes lag)

42
Q

Assessing severity of pneumonia

A

CURB-65 helps assess mortality risk

C: confusion

U: urea

R: resp rate

B: BP hypotensive

65 age

43
Q

Management of pneumonia

A

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 +

44
Q

Why does HAP happen and how is it managed

A

Px severely ill stay > 1w -> change normal flora and aspirate

Early: co-amoxiclav

Late: Piperacillin-tazobactam

45
Q

Aspiration pneumonia cause consequence and management

A

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

46
Q

Definition and types of pneumothorax

A

Air in pleural space leading to lung deflation.

1) Primary (normal lung)
2) Secondary (underlying lung disease)
3) Tension

47
Q

Causes of pneumothoraces by type

A

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
48
Q

Presentation of pneumothorax

A

ACUTE onset of SOB, pleuritic chest pain (PE same)

Tension: assd raised JVP, hypotension

49
Q

Inv pneumothoraces

A

CXR

dont wait for CXR if high suspicion of tension

50
Q

Management of pneumothoraces

A

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

51
Q

Define Pleural effusion

A

Accumulation of fluid in pleural space

52
Q

Two types of pleural effusion and causes

A
  1. Transudate
  • Clear
  • Low protein
  • Failures (Heart, Liver, Renal)
  • Hypo-albuminemia
  1. Exudate
  • cloudy
  • high protein
  • Infection (paraneumonic, empyema, TB)
  • Malignancy
  • PE
  • Inflammatory
53
Q

Presentation of px with pleural effusion

A

SOB, pleuritic chest pain, cough + symptoms reld to cause

54
Q

Diagnostic investigation of pleural effusion

A

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
    *
55
Q

Management of transudate pleural effusion

A

Treat underlying cause

56
Q

Management of exudate pleural effusion where cause is infection (para-pneumonic)

A

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

57
Q

Management of exudate pleurla effusion when cause is infection (empyema)

A

URGENT DRAIN because fluid is infectious

long course abx

consider surgery/ct thorax

58
Q

Management of exudate pleural effusion when cause is infection (TB)

A

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

59
Q

Management of exudate pleural effusion when cause is malignancy

A

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)

60
Q

Define a pulmonary embolism

A

Embolus from thrombus usually of deep veins in leg or pelvis, that lodges in pulmonary arteries

61
Q

RF for PE

A
  1. Recent surgery
  2. History of VTE
  3. Oral contraceptive
  4. Pregnancy
  5. Coag disorders
  6. Malignancy
  7. Obesity
  8. Age > 60
  9. long haul travel
62
Q

Presentation of PE

A
  • 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
63
Q

Investigating PE

A
  • 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
64
Q

Management of a PE

A
  1. If massive PE: clot buster (alteplase)
  2. Otherwise: anticoag (fondaparineux or LMWH)
  3. Then may have longterm DOAC (-ban) or VKA (warfarin)
65
Q

Define TB

A

A curable bacterial infection caused by mycobacterium tuberculosis that is contageous when effcting lungs.

Results in granulomatous inflammation

66
Q

Pathophysiology of TB

A

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

67
Q

Types of TB

A

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

68
Q

Latent tb screening

A

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

69
Q

Presentation of TB

A
  • Fever
  • Weight Loss + fatigue
  • Night sweats

May also get cough, haemoptysis, abdo pain, headache, back pain bc tb can effect everywhere

nb dd cancer

70
Q

Miliary TB

A

Millet seed pattern throughout lung parenchyma

Signifies systemic dissemination of TB

71
Q

Causes of granulomatous inflammation other than TB

A
  1. Sarcoidosis
  2. Crohns
  3. GPA (vasculitis)
  4. Infection
  5. Foreign body
72
Q

Management of TB and SE

A

6 months NB 9-24 if drug resistant

2 months RIPE

Rifampicin (orange)

Isoniazid (peripheral neuropathy)

Pyrazinamide (hepattox)

Ethambutol (eyes)

4 months RI

73
Q

How is TB diagnosed

A

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

74
Q

What is sore throat and the main infectious causes

A

Pharyngitis +- tonsilitis

Mostly viral

important bac cause: Group A strep

75
Q

Group A Strep Pharyngitis inv, management and complications

A

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

76
Q

What is diptheria, complications and mangement

A

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

77
Q

What is glandular fever/infectious mononucleosis, presentation, diagnosis, management

A

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

78
Q

Organisms causing sinusitis/otitis media

A

same organisms that cause URTi

  1. Viruses (majority)- RSV, rhinovirus
  2. Bacteria - pneumococcus, haemophilus influenza
79
Q

Presentation of otitis media + sinusitis

A

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)

80
Q

Management of OM/sinusitis and complications of sinusitis

A

Decongestants, rarely abx

Grommet for recurrent OM

Complications of sinusitis:

Mastoiditis

Meningitis (pneumococcal)

Intracranial abscess

81
Q

What is epiglottitis, cause, presentation, diagnosis, management

A

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)

82
Q

What is whooping cough, cause, presentation, diagnosis, management

A

Highly infectious bacterial infection caused by Bordetella Pertussis. rare = vaccine

Present:

  1. 2 weeks: standard virus symptoms, coryza BUT highly infectious
  2. 2-6 weeks: intense cough
  3. chronic cough

Diagnose: PCR swab

Manage: a macrolide abx

Consequence: fail thrive, apnoea, pneumothorax, subcut emphysema, brain damage

83
Q

What is croup, cause, presentation, diagnosis, management

A

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

84
Q

Flu - causes, symptoms, diagnosis, complications, management

A

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)

85
Q

What is bronchiolitis, cause, pres, diagnosis + outcomes

A

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

86
Q

Define exacerbation of COPD

A

change in baseline in 2/3 of:

  • Volume of sputum
  • character of sputum
  • breathlessness/wheeze
87
Q

Organisms causing acute exac of COPD

A

Bacterial:

  • pneumococcus
  • haemophilus
  • moraxella catarrhalis
  • ecoli, klebsiella

Viral:

  • RSV/rhino/flu/adeno

Non infective

88
Q

Management of COPD exac

A

Bronchodilation: salbutamol + ipratropium

Steroid: prednisalone

May need abx

89
Q

Interstitial lung disease definition, causes, presentation and tx

A

scarring at interstitium

Causes:

1) idiopathic
2) infection
3) secondary to exposure

Present with SOB

Treat steroids but poor prognosis

90
Q
A

CC2 (8 decks)

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