Respiratory Flashcards
What is the main risk factor for COPD?
Smoking
What condition does alpha1-antitrypsin deficiency make you more susceptible for? And what is the usual age of onset?
COPD (lung disease) and Liver disease. Lung disease usually comes on at the age of 20-50.
What are the signs of emphysema? (PP or BB)
Pink Puffer = Barrel chest, pursed lips, muscle wasting
What is the pathology of emphysema?
Reduced elasting which causes reduced surface area –> collapsed alveoli. Due to reduced recoil this causes air trapping.
What would the blood gases look like for a patient with suspected emphysema?
Normal. Due to the effort they put in (pursed lips).
What are the signs of Chronic Bronchitis? (PP or BB)
BB = Productive cough, oedema and raised JVP. VQ mismatch and right heart failure. Fibrosis may be present and they may be hypoxic.
What is the pathology of Chronic bronchitis?
Hypersecretion and reduced cilia = airway obstruction
What are the 2 main investigations for COPD diagnosis - and what would they show?
Chest X-ray –> flat diaphragm and hyperinflated
Spirometry - reduced exhalation. FEV1:FVC = less than 70%
What is the 1st line treatment for COPD (in most patients - non-pharmalogical)?
SMOKING CESSATION
What are the pharmacological options for patients with COPD? (1st option –> if there are exacerbations –> oral –> aids –> surgery)
Inhaler = B2 agonist (salbutamol) or M3 antagonist
+ corticosteroid inhaler if there are exacerbations
Oral = Theophylline (dilation) or Macrolides - reduce exacerbations for ex-smokers
Aids = Oxygen - long term or ambulatory
Surgery = Lung transplant or resection (remove damaged area so the rest is more efficient)
What is the definition of asthma?
Reversible widespread bronchoconstriction which varies over time.
What are the symptoms of asthma? (is there a time pattern)
Breathlessness Chest tightness Cough Wheeze - diurnal variation
Non-specific triggers of asthma?
Exercise, cold air, fumes and smoke
Specific triggers of asthma?
Allergens
What are the 2 forms of asthma?
Atopic (allergic) or Intrinsic
Atopic asthma - When is the onset? What are other common co-morbidities? What antibody is produced and where? How do they respond to treatment?
Childhood onset
Eczema and rhinitis
IgE - systemically (skin prick test)
Good response to treatment
Intrinsic asthma - When is the onset? What are other common co-morbidities? What antibody is produced and where? How do they respond to treatment?
Late onset (adulthood)
Sinusitis and polyps
IgE - locally
Reduced response to treatment - increased response when steroids are used.
Which cells in the lamina propria are increased in asthma- and what are their roles (3)
Mast cells - histamine release Neutrophils - pro-inflammatory T2 helper cells - become unregulated - IL 13/4 = activate mast cells - IL 9 = Activate MC complex - IL 5 = increased eosinophils
What are the 2 stages of a asthma attack?
Early - rapid FEV1 drop - mast degranulation
Late (4-12 hours) - eosinophil recruitment - gradual FEV1 drop
What are the investigations for asthma (2)?
FeNO - 40ppb +
Spirometry - FEV1:FVC = less than 70%
- What is the reliever treatment for asthma? (when do you move to next treatment) ?
SHort acting B2 agonist (salbutamol)
Move up pathway if using 3+ times a week
- Initial preventer treatment for asthma?
Low dose inhaled corticosteroid - beclomethasone
- Add on preventer treatment for asthma?
Long acting B2 agonist (salmeterol)
- 2nd add on for asthma?
Anti-leukotrienes (Montelukast) - reduce constriction and anti-inflammatory.
Theophylline - Increase cAMP (bronchodilator)
Long acting muscarinic antagonist (ipratropium) - reduce constriction and mucus
- Last resort treatment for asthma (medication)?
Oral steroids (prednisolone)
What are the 3 things to give in a status asthmaticus?
Oxygen + B2 agonist nebuliser + Steroid (IV hydrocortisone/prednisolone)
If the first treatment for status asthmaticus doesn’t work (15-20 mins) what should be given next?
Ipratropium and Magnesium (reduces calcium levels)§
Multisystem disorder characterised by noncaseating granulomatous inflammation - What condition is this?
Sarcoidosis
A patient presents with sudden onset dyspnoea accompanied with some chest pain and a cough. They have a fever and have felt general malaise recently. They also state that they feel their clothes have been getting loser and they haven’t wanted food as much recently. O/E they have red bumps on their legs which are warm to the touch, hard and painful. They also have some anterior uveitis and mention some of their joints have been painful recently. What is the most likely diagnosis and how would you further investigate?
Acute sarcoidosis. Want to do bloods: - increase in inflammatory markers - Normal ACE, IgG, Calcium and ALP Pulmonary function tests Chest x-ray = hilar lymphadenopathy.
What is the treatment/management for acute sarcoidosis?
Majority will resolve spontaneously if more severe than can give bed rest and NSAIDs. Steroids and immunosuppressants if continuously severe.
What are the symptoms of chronic sarcoidosis? (A GRUELLING Disease)
ACE increase Granulomas Arthritis Uveitis Erythema nodosum Lymphadenopathy Lupus pernio Idiopathic Non-caseating Gammaglobulinemia Vitamin D increase (calcium increase)
A patient comes in with left hyper resonance, Right tracheal deviation and a raised JVP. What is the most likely diagnosis and which side?
Left sided tension pneumothorax
What is a pneumothorax?
Air in the pleural space causing partial or total lung collapse
When and in who are pneumothorax most likely to occur?
More likely in men
Peak at 20-30 years and at 60-70 years
What is the presentation of a pneumothorax and how may they differ between the old and young?
Young = chest pain (anterior radiating to the back)
Old = Dyspnoea
Non-productive cough
Tympanic resonance and decreased respiratory murmur over the affected side.
12% can be asymptomatic
What is the difference between type 1 closed pneumothorax and type 2 open pneumothorax?
Type 1/Closed = spontaneous. Usually due to a small visceral pleura laceration which can spontaneously close and the air is reabsorbed. No invasive treatment is required.
Type 2/Open = Most likely due to lung disease (emphysema). Due to a large laceration in the visceral or parietal pleura which is unable to close. There are repeated shifts of the mediastinum and needs to be treated immediately!
How would you deal with a small asymptomatic pneumothorax?
Bed rest - lie of affected side, anticoagulate and give oxygen. Can be discharged.
In what pneumothorax case would you aspirate with a 16-18g cannula? And what would you do after aspirating?
Aspirate in 2nd intercostal space mid clavicular
Large primary or small secondary pneumothorax. Symptomatic patient.
Put on high flow oxygen and observe.
If a patient with a pneumothorax has been aspirated and has not improved or they have a large secondary pneumothorax what would you do?
Put in a chest drain - until there is no leak of air and the lung has expanded and fluid is being removed.
Chest drain into 5th-6th intercostal space mix axillary.
What is a tension pneumothorax?
Ruptured tissue causes a valve to be made so on inspiration air enters the cavity and on expiration it doesn’t leave causing there to be a total lung collapse.
Causing there to be a big mediastinal shift.
What is and when does vena cava kinking occur?
Vena cava gets compressed in a tension pneumothorax causing there to be decreased venous return = reduced cardiac output. This can lead to a arrhythmia.
What is the treatment for a tension pneumothorax?
MEDICAL EMERGENCY!
Immediate aspiration - cannula 2nd intercostal space midclavicular. Then a chest drain to be placed in once the initial relief has occurred.
When would surgery be thought about in the case of pneumothoraces?
Recurrent episodes
First episode but a high risk patient
Prolonged air leak
What are the surgical options for pneumothoraces?
Resection of a bullous dystrophic lung. Video assisted thoracic surgery. Can be a apex, bleb(mm), Bullae (cm) or giant bullae (over 1/3rd)
Pleurodesis - abrasion of parietal pleura (stick lung to chest so that nothing can get in the pleural space).
Pleurectomy = removal of parietal pleura. Create strong pleuroparenchymal adhesions.
What drug can people not have post-pleurectomy?
NSAIDs§
What is the primary mutation found in cystic fibrosis?
DeltaF508
What is a normal CTFR and how does it work/what does it do?
Epithelial chloride channel - bronchial
Inactive form is inserted and then activated by ATP
It moves 90% of the chloride and negatively regulates the Na channel
What is the consistency of normal mucous in the respiratory tract?
Thin layer with high elasticity and low viscosity
- traps particulates and pathogen and moves them along the mucociliary escalator
H2O, Na, and Cl move to maintain this
What are the consequences of having the delta F508 mutation?
CTFR is never expressed = CF
What is the pathophysiology of cystic fibrosis?
Large mucous production (thick) causing the failure of the mucociliary escalator.
More sodium into the cell due to the lack of negative regulation from the CTFR - increased activity of Na/K ATPase also causes a huge energy loss
Due to the increased sodium in the cell the water also moves into the cell causing the mucous to be thick
Cilia are unable to beat due to large amount of mucous causing bacterial colonisation
What is the role of neutrophils in cystic fibrosis?
Move in to the mucous to try and clear the bacteria however become frustrated and phagocytose releasing O₂⁻ and proteases which leads to lung tissue destruction
A 2 yr old child presents to the GP with their 4th chest infection in the year in which they are coughing up a lot of mucous. The child is generally failing to thrive and is on the 95th centile for weight and height. The child has also noticed that their sweat is very salty. What is the most likely diagnosis and what signs would you expect to see O/E?
Cystic fibrosis
- finger clubbing
- cyanosis
- coarse crackles over areas of bronchiectstasis
What are important differentials to think about in a cystic fibrosis presentation?
Pneumonia, malignancy, PE
coeliac if there is abdominal involvement
Primary ciliary dyskinesia
What investigations would be done for a query cystic fibrosis?
Bedside
- urine dip = in case of diabetes
- Lung FTs - obstructive picture is most common
Bloods = FBC, U+Es, LFTs, CRP, glucose, vitamins (A, E,C)
Sputum culture - haemophilus influenza, staph aureus, pseudomonas aeruginosa
Sweat testing = high chloride (98%)
Genetic testing - CTFR
Stool test - faecal elastase (pancreatic insufficiency)
Imaging - CXR = bronchiectasis and hyperinflation
HRCT - bronchial thickening and bronchiectasis. Mucous plugging
CT angio - if there is haemoptysis
What is the management of cystic fibrosis?
Physiotherapy and mucolytic agents to help clear the mucous. Prophylactic antibiotics (azithromycin) and early antibiotics in the case of acute exacerbations
What is the main bacteria for TB?
Mycobacterium Tuberculosis
How is TB spread?
Via droplet spread - sustained close contact
What is the pathogenesis of TB?
MBTB goes into pulmonary alveoli –> alveolar macrophages and it replicates in them –> lymphocytes and fibroblasts come to the infected macrophage and cause granulation formation (protects the TB from spreading) –> centre of the granulation can die-caseous necrosis and lead to latent TB
What is the main presentation of TB?
Pulmonary only (90%) cough +/- haemoptysis and shortness of breath for more than 2-3 weeks. Also have fever, night sweats and weight loss
What are possible extrapulmonary symptoms of TB?
Only 10% of cases
Meningitis, choroiditis (red and inflamed eye), lupus vulgaris, constrictive pericarditis, dysuria, haematuria, RIF mass/pain, ascites, arthritis, osteomyelitis
How is active TB diagnosed?
Chest x-ray - patchy nodal shadows (upper lobe)
3 sputum samples (seperate times and 1 in morning)
Ziehm-neelson - acid fast bacilli (50%)
How is latent TB diagnosed?
TST test to screen high risk patients
Interferon gamma release assay
What is the biggest risk for TB?
HIV
where in the lung does TB primarily stay?
Ghon focus (upper lobe)
What is the treatment for active TB?
Multi drug regime = isoniazid, pyrazinamide, ethambutol, rifamycins
What is a possible side effect of ethambutol?
Optic neuritis - red/green colourblindness
What is the treatment for latent TB?
single antibiotic for 3-6 months
What is bronchiectasis?
Permanent dilation of bronchi - irreversible bronchial wall damage
What are the causes of bronchiectasis?
Post infection - TB, childhood LRTI, ABPA
COPD/Asthma
primary ciliary dyskinesia, CF, alpha 1 anti-trypsin deficiency
RA
SLE
Sarcoidosis
Idiopathic (40%)
What is the pathophysiology of bronchiectasis?
trauma –> immune recruitment –> inflammation –> loss of elastin and muscle = dilatation.
This increases the colonisation of bacteria which further causes inflammation and damage –> dilation
How may bronchiectasis present? (signs and symptoms)
Cough - daily, mucopurulent, haemoptysis (50%) Dyspnoea rhinosinusitis - facial ache Fatigue Clubbing Coarse crepitus rhonchi (snoring) high pitched inspiratory squeaks and pops
What bedside investigations could be done to confirm bronchiectasis?
Sats Sputum sample - pseudomonas aurgelia /haemophilus influenza lung function tests - obstructive ECG - can cause pulmonary hypertension (tall R waves and RAD) FBC, CRP autoimmune screen IgE (ABPA) CF genetic test (F508)
What imaging can be done to confirm bronchiectasis?
CXR = severe - tram lines and ring shadows
HRCT - gold standard = bronchial dilation and thickening
Bronchoscopy - if it is localised
Differential diagnosis for bronchiectasis - productive cough, dyspnoea, fatigue and rhinosinusitis?
COPD
Asthma
Pneumonia
chronic sinusitis
What is the conservative management for bronchiectasis?
pulmonary rehab - physio
smoking cessation
vaccination - flu and pneumonia
What is the medical management for bronchiectasis?
Mucoactive agent
long term antibiotics
bronchodilator - formoterol
Long term oxygen
Surgery options for bronchiectasis and when to do them?
Lung resection
Lung replacement - if under 65, quickly worsening and no treatments have been effective
What is pneumonia?
Infection of the lung tissue causing inflammation of the lung parenchyma and sputum fills the airways and alveoli
What classifies as hospital acquired pneumonia?
48hrs after hospital admission
What are the symptoms of pneumonia?
Shortness of breath Productive cough haemoptysis pleuritic chest pain fever delirium
What are the signs of pneumonia?
Tachypnoea tachycardia hypoxic hypotension bronchial breathing focal coarse crackles dullness on percussion
What does the CURB-65 score determine and what are the points for it?
Confusion Urea >7 Respiratory rate >30 BP <90 systolic if they are 65 and older
0-1 = home treatment 2 = hospital admission 3+ = ICU
What are the 2 main causes of pneumonia?
Streptococcus pneumoniae
Haemophilus influenza
What are atypical causes of pneumonia (2) and how may people contract them/what are specific signs?
Legionnaires - hot tubs/AC. Causes SIADH = hyponatremia
Mycoplasma pneumoniae = erythema multiforme
What investigations would be carried out if a patient was in hospital for pneumonia and what might be added on if they have severe pneumonia?
CXR = consolidation
FBC, CRP, U+Es
Severe = sputum and blood culture and urinary antigens
What is the treatment for mild and severe CAP?
Dependent on each trusts policy
mild = 5 day oral antibiotics - amoxicillin or macrolide
severe = 7-10 days oral antibiotics - amoxicillin and a macrolide
What are possible complications of pneumonia?
sepsis pleural effusion empyema Lung abscess death
What is a pleural effusion?
Collection of fluid in the pleural cavity
What is exudate and what type of pleural effusion is this related to +examples ?
>3g protein - related to inflammation lung cancer pneumonia RA TB
What is transudate and what type of pleural effusion is this related to and examples?
<3g protein - fluid shift relation congestive cardiac failure hypoalbuminemia hypothyroidism Meigs syndrome - right pleural effusion secondary to ovarian malignancy
A patient comes into the GP for shortness of breath that came on quite suddenly. On examination there is dullness of the right sided lung base and reduced breath sounds in this area. The trachea is deviated to the left.. What is the most likely diagnosis and management plan?
Pleural effusion
CXR = costophrenic blunting, fluid in the fissures
If its large - meniscus and tracheal and mediastinal deviation.
Fluid sample
Treatment
- small - resolve underlying cause
large = aspirate and chest drain
What is empyema?
infected pleural effusion
- pus, acidic, decreased glucose and increased LDH on the aspiration
Drain and give antibiotics
What is pulmonary hypertension and what can it lead to?
Increased resistance and pressure in the pulmonary arteries leading to right heart strain and increased systemic venous pressure
What are the 5 groups of pulmonary hypertension causes?
1 = primary PH or CT disease (SLE) 2 = Left heart failure 3 = chronic lung disease (COPD) 4 = pulmonary vascular disease (PEmbolism) 5 = Misc - sarcoidosis, glycogen storage disease
What is the presentation for pulmonary hypertension?
Shortness of breath syncope tachycardia Increased JVP hepatomegaly peripheral oedema
What could possibly be seen on a ECG of a patient with pulmonary hypertension and why?
Right ventricular hypertrophy - increased R waves in V1-3
- right axis deviation
- RBBB
What investigations can be done in the case of suspected pulmonary hypertension?
BNP
CXR
ECG
ECHO
What is the management for primary pulmonary hypertension?
IV prostanoids
Endothelin receptor antagonists
Phosphodiesterase-5 inhibitors
What are interstitial lung disease?
Conditions that affect the parenchyma causing inflammation and fibrosis
What are the general symptoms for interstitial lung disease?
Progressive exertional dyspnoea
dry cough
arthralgia
malaise
What is most likely to be found on examination of a patient with interstitial lung disease?
bilateral fine end inspiratory crepitations (velcro)
clubbing
Possible pulmonary effusion
How is interstitial lung disease diagnosed?
HRCT - ground glass, honeycombing, bronchiectasis and opacities
Biopsy if HRCT is not clear
What are the more specific symptoms/history of idiopathic pulmonary fibrosis?
3+ history of symptoms
no clear cause
50+
What 2 drugs can be used for idiopathic pulmonary fibrosis?
Pirfenidone = antifibrotic and anti inflammatory
Nintedanib - monoclonal antibody for tyrosine kinase
What drugs can cause interstitial lung disease?
Amiodarone, cyclophosphamide, methotrexate, nitrofurantoin
What are the causes of secondary pulmonary fibrosis ?
Alpha-1 anti-trypsin deficiency RA SLE Sclerosis Sarcoidosis
What is cryptogenic organising pneumonia and what is the treatment for it?
Focal inflammation (consolidation) - oral corticosteroids
What properties does asbestos have and what conditions/signs is it likely to cause?
Fibrogenic and oncogenic
- fibrosis, pleural thickening and plaques
adenocarcinoma/mesothelioma
