Respiratory AS Flashcards
What are the stages of clubbing?
Important nail sign of systemic disease linked with underlying pulmonary, cardiovascular, neoplastic etc.
Described as bulbous uniform swelling of soft tissue of the terminal phalanx of digit between nail and nail bed.
- Periungual erythema and softening of the nail bed (Bogginess + fluctuance of nail bed).
- increase in angle between proximal nail fold and nail plate. (loss of concave nail fold angle
- increased longitudinal and transverse curvature
- soft tissue expansion at distal phalanx (drumstick)
Causes of Clubbing?
Respiratory - Carcinoma (Bronchial + Mesothelioma) - Chronic lung suppuration Empyema, abscess Bronchiectasis, CF - Fibrosis Idiopathic pulmonary fibrosis TB
Cardiac
- Infective endocarditis
- Congenital cyanotic heart disease
- Atrial myxoma
GIT
- Cirrhosis
- Crohns’ UC
- Coeliac
- Cancer: GI lymphoma
Other - Familial - Thyroid acropachy - Upper limb AVMs or aneurysm Unilateral clubbing
What is cyanosis?
Blue discolouration of mucosal membranes or skin
Deoxygenated Hb >5g/dl
Classification of cyanosis?
Peripheral: cold, blue nails
Central: blue tongue, lips
Causes of cyanosis? Pathophysiology
Think of O2 cascade - The OC is the process of diminishing or declining O2 tension from the atmospheric environment down to the cellular level, specifically the mitochondria.
As it moves down through the body to the cell, O2 will be diluted down, extracted or lost, so that at cellular level the PO2 may be 3 or 4 mm/Hg.
Causes of Cyanosis
Respiratory
- Hypoventilation: COPD, MSK
- Decreased diffusion: Pulmonary oedema, fibrosing alveolitis
- V/Q mismatch: PE, AVM (HHT) - Some areas of the lungs receive perfusion but no oxygen, or some receive oxygen but no perfusion.
- inadequate transport of oxygen by haemoglobin
Cardiac
- Congenital: Transposition of great arteries, Tetralogy of Fallot
- Decreased Cardiac Output: Mitral stenosis, Systolic LVF
- Vascular: Raynaud’s, DVT
RBC
- Low affinity Hb, may be hereditary or acquired
What is pneumonia?
Inflammation of the lungs with consolidation or interstitial lung infiltrates, categorised by causative organism.
Anatomical classification of pneumonia?
Bronchopneumonia
- Patchy consolidation of different lobes
Lobar Pneumonia
- Fibrosuppurative consolidation of a single lobe
- Congestion (vasculuar congestion + alveolar oedema) –> red (erythrocytes, neutrophils, desquamated epithelial cells)–> grey (fibrinopurulent exudate) –> resolution
Aetiological classification - community acquired pneumonia? Organisms?
- Pneumonia acquired outside hospital.
- Group of signs + symptoms related to LRTI with fever >38, cough, expectoration, chest pain, dyspnoea, and signs of invasion of alveolar space.
Typical Bacteria
- Streptococcus Pneumoniae (most common CAP).
- Haemophilus influenza
- Staphylococcus aureus
- Moraxella Catarrhalis
Atypical bacteria
- Mycoplasma pneumoniae
- Chlamydophilia pneumoniae
- Legionella pneumophilia
- Chlamydia psittaci
Virus
- Influenza A/B
- RSV
- Adeno/Rhin
Aetiological classification - Hospital Acquired Pneumonia? Organisms?
HAP is an acute LRTI this is by definition acquired after at least 48hr of admission to hospital and is not incubated at time of admission.
Bacteria cause most HAP (mostly aerobic gram-negative bacilli)
- Pseudomonas Aeruginosa
- Escherichia coli
- Klebsiella Pneumoniae
- Acinetobacter
- MRSA
Aetiological classification - Aspiration Pneumonia?
= Results from inhalation of oropharyngeal content into lower airways that leads to bacterial infection. Commonly due to recent intubation on ITU.
- Commonly due to altered swallow/gag. increased risk from patients with stroke, bulbar palsy, decreased GCS, GORD, Achalasia.
- Aspiration causes an inflammatory reaction called pneumonitis, results in damage to lung parenchyma. Leads to inflammatory reaction and ultimately aspiration pneumonia.
- Often Strep Pneumoniae, Staphylococcus aureus, Haemophilus influenza, Pseudomonas aeruginosa.
- Used to be anaerobes (Bacteroides, Porphyromonas).
Immunocompromised Pneumonia?
Pneumocystis Jirovecii Pneumonia (PCP), Aspergillosis, TB, CMV/HSV.
Symptoms of Pneumonia?
- Fever, Rigors
- Malaise, anorexia
- Dyspnoea
- Cough, purulent sputum, haemoptysis
- Pleuritic pain
Signs of Pneumonia?
- Increased RR
- Increased HR
- Cyanosis
- Confusion
- Consolidation (filled with liquid not air)
Decreased expansion
Dull Percussion
Bronchial breathing
Decreased air entry
Crackles
Pleural rub
Increased vocal fremitus
Risk factors of pneumonia?
Age >65 COPD Exposure to ciggy smoke Alcohol abuse HIV use of steroids, antipsychotics, PPIs.
Investigations for Pneumonia?
Bloods: FBC (WBC) , U+E (severity scoring),
LFT (risk factor for patients with cirrhosis, CLD),
CRP (raised) - normally lags in comparison to WCC in treatment of bacterial infection.
Culture (pre-treatment),
ABG (if SpO2 to indicate severity) low, glucose can be elevated.
Urine: Ag test (pneumococcal, legionella)
Sputum: MC+S
Imaging: CXR (infiltrates, cavities, effusion, consolidation)
Special Tests of Pneumonia?
Special test - Paired sera Abs for atypicals Mycoplasma, Chlamydia, Legionella - Serum Procalcitonin - Immunofluorescence (PCP) - BAL - Pleural tap - pleural effusion - Rapid antigen testing for virus)
Assess severity of pneumonia?
Severity: CURB-65 (only if x-ray changes)
- Confusion (AMT <8)
- Urea >7
- resp Rate >30/ mins
- BP <90/60
- > 65 yr old
Score of 0-1 –> home management
2 –>Hospitalisation
3-5 –> ICU admission 30 day mortality 15-30%.
CRP < 20 mg/L - do not routinely offer antibiotic therapy
CRP 20 - 100 mg/L - consider a delayed antibiotic prescription
CRP > 100 mg/L - offer antibiotic therapy
General Management of pneumonia - Outpatient?
- Consider limitations of severity score
Ability to maintain oral intake, history of substance abuse, severe comorbid illness, cognitive impairment, impaired functional status, availability of outpatient support resources - Advise not to smoke, to rest, stay hydrated.
- Advise them to report any chest pain, SOB or lethargy.
- Reassess at 48hrs.
- Repeat examination after 10-14 days
General Management of pneumonia - Inpatient?
- If hospital admission needed Abx O2: Pa02 >8, SpO2 94-98% Monitor Sats Fluids Analgesia Chest Physio Consider ITU if shock, hypercapnea, hypoxia
F/up @ 6 weeks with CXR to allow for radiological changes.
Do not routinely discharge if in the past 24hr they have 2 more more
- Temp 37.5
- RR 24
- HR >100
- SBP 90
- O2 <90
- Abnormal mental status
1 week - Fever should be gone
4 weeks - chest pain + sputum production should have substantially reduced
6 weeks - cough + breathlessness reduced
3 months - most symptoms resolved maybe some fatigue
6 months - most feeling normal
Antibiotic management for outpatient pneumonia?
If CURB-65 = 0
Amoxicillin - 1g PO TDS OR doxycycline 100mg PO BDS OR clarithromycin 500mg PO BDS (where resistance)
If CURB-65 1 or 2 = Amoxicillin + clarithromycin OR doxycyclin 200mg on first day.
- Consider influenza antiviral cover (Tamiflu)
If comorbidies (DM, chronic heart, liver, renal disease give co-amoxiclav + clarithyromycin
Antibiotic management for inpatient pneumonia?
- IV cefuroxime/ceftriaxone (1-2g IV every 8hr, every 24hr for ceftriaxone) + clarithromycin 500mg orally BDS.
- Add fluclox if staph suspected.
Antibiotics for MRSA cover?
Vancomycin (15mg/kg IV every 12hrs) - consider teicoplanin.
Linezolid (600mg IV every 12hrs) (second line.
MRSA swabbing - nasal and skin lesion or wounds.
Suppression of MRSA once carrier found - mupirocin in white soft paraffin.
Chlorhexidine gluconate.
Antibiotics for pseudomonas cover?
Tazocin 4.5mg IV every 6hr
Atypical bacterial pneumonia management?
Generally speaking - Clarithromycin
Azithromycin 500mg orally, then 250mg OD for 4 days
- For Psittacosis and Q fever (Coxiella burnetii) use doxycyline 100mg orally
- Legionella/Chlamydia pneumonia - Azithromycin 500mg, levofloxacin 750mg OD, IV
- PCP - Co-trimoxazole 80/400mg (trimethoprim + sulfamethoxazole)
Hospital-acquired pneumonia management?
If within 5 days of admission. First line - Non severe = Co-amoxiclav 500/125mg 3x a day then review.
Then consider Doxycyline/Cefalexin.
If more than 5 days after admission. If septic/high risk of resistance - PipTaz - Ceftriaxone - Meropenem
If patient has no risk factor for resistance pathogen - likely to be Strep Pneumonia, Haemophilis influenza, Staph A, E.coli, Klebsiella, Enterobacter, Proteus.
- Pseudomonas management = tazocin/ceftazidime.
Severe HAP - Likely to be Pseudomonas aeruginosa, K pneuonaemia (ESBL), Acinetobacter, MRSA, Legionella.
Need Ceftazidime, imipenem/meropenem, piptaz.
OR
Tazocin ± vanc ± gent for 7 days.
Antibiotic for gram negative HAPS (Pseudomonas, Klebsiella)
Cephalosporin - ceftazidime Carbapenam - meropenem/ imipenem/colastatin Beta-lactamase inhibitor (pip-taz) Fluoroquinolone (cipro/levofloxacin) Gentamicin
Antibiotics with gram positive pathogen HAPS?
MRSA = Vancomycin or linezolid
ESBL HAP?
Carbapenem
Then Fluoroquinolone
Pneumovax?
Vaccine for pneumococcus for hi-risk adults.
> 65 yrs old
Chronic renal, heart, kidney failure or conditions
DM
Immunosuppression: hyposplenism, chemo, HIV
CI: P, B, Fever
Revaccinate every 5yrs
Complications of Pneumonia - respiratory failure?
Respiratory Failure
- Type 1: PaO2 <8kPa + PaCO2 <6kPa (acute hypoxic respiratory failure)
- Type 2: PaO2 <8kPa + PaCO2 >6kPa (hypercapnic resp failure + hypoxia).
Type 1
- Severe hypoxaemia (fluid in alveoli, collapse of alveoli etc)
Type 2
- Hypercapnic (poor ventilatory muscle, obstruction of airways (COPD), secretion in small airways (Cystic fibrosis)
Management: oxygen, ventilation
Other complications of pneumonia - Hypotension?
Hypotension - septic vasodilation + Dehydration
- Management
= if SBP <90 –> Fluid challenge 250ml over 15mins
If no improvement: central line + IV fluids
If refractory: ITU for inotropes
Other complications of pneumonia - AF?
Usually resolves with Rx
Management: digoxin or B-B for rate control
Other complications of pneumonia - pleural effusion?
Indicator of pneumonia severity.
- Exudate
- Mx: tap and send for MC+S, cytology and chemistry
Complicated pleural effusion - Should be treated, on its way to becoming an empyema. f
Other complications of pneumonia - Empyema?
- Pus in the pleural space
- Associated with pneumonia.
- Patients have signs of infection and a significant pleural effusion.
- Anaerobes, Staph, Gm-ve
- Assoc with recurrent aspiration
- Pt with resolving pneumonia develops recurrent fever
- Tap : turbid, pH <7.2, decreased glucose, increased LDH
Management: US guided chest drain must be inserted+ Abx.
Lung Abscess causes?
A circumscribed collection of pus in lung leading to cavity formation usually with an air-fluid level visible on chest x-ray.
- Aspiration (altered consciousness + NG tubes)
- Bronchial obstruction: tumour, foreign body
- Septic emboli: sepsis, IVDU, RH endocarditis
- Pulmonary infarction and secondary infection
- Subphrenic/hepatic abscess
- Complication of pneumonia
Features of a lung abscess?
- Swinging fever (high grade)
- Cough, foul purulent sputum (indicative of anaerobes)
- haemoptysis
- Murmur due to cardiac murmur (bacterial endocarditis)
- Cavernous breath sounds
- Malaise, weight loss
- Pleuritic pain
- Clubbing
- Empyema
Tests for a lung abscess?
- Blood: FBC (WBC), ESR, CRP, cultures
- Sputum: micro, culture, cytology
- CXR: cavity with fluid level, consolidation with central cavitation and air-fluid level.
- Consider CT and bronchoscopy - usually a round cavity with irregular margins - no signs of compression of surrounding lung.
- Bronchoscopy (proximal airway obstruction by tumour).
Management of lung abscess?
- Abx according to sensitivies
(ceftriaxone + clindamycin) - Aspiration + postural drainage.
- Surgical excision
Other complications of pneumonia?
- Sepsis
- Pericarditis/myocarditis
- Jaundice (usually cholestatic)
due to sepsis, drugs (fluclox, augmentin), mycoplasma, legionella.
Sepsis criteria?
Updated version:
Low risk
- Normal RR (<21), BP (SBP >100), HR (<90), Urine output, temp, no non-blanching rash.
Moderate risk / (high risk)
- Altered behaviour
- Impaired immunity, trauma or surgery
- RR 21-24 (high = >25)
- SBP 91-100 (high = <90)
- HR 91-130 (high = >130)
- No urine passed in previous 12-18 hrs.
- Signs of infection
- Mottled appearance/ non-blanching rash
Outdated version >2 =
- Temperature >38 or <36,
- HR >90
- RR >20, or PaCo2 <4.6
- WCC: >12x10^9, <4 x10^9
Sepsis definition?
SIRS caused by infection (Systemic inflammatory response syndrome)
Severe sepsis definition
Sepsis with at least 1 organ dysfunction or hypoperfusion
Septic shock
Severe sepsis with refractory hypotension
- (persistent hypotension requiring vasopressors to maintain MAP >65
- Serum lactate level >2mmol despite adequate volume resuscitation
Specific pneumonia - pneumococcus - gram positive diplococcus
RF: Elderly, EToH, immunosuppresed, CHF, pulmonary disease.
Rapid onset, high fever, pleuritic chest pain, herpes labialis.
Pulmonary features: Lobar consolidation.
Extrapulmonary: Herpes labialis. Causes reactivation of herpes simplex virus resulting in cold sores.
Management - Amoxicillin, BenPen, cephalosporins
Specific pneumonia
- S.aureus?
RF: Influenza infection, IVDU, Co-morbidities.
Commonly occurs after patients have had an influenza virus.
Pulmonary features - Bilateral cavitating bronchopneumonia
Management: Fluclox or Vanc alongside amoxicillin.
Specific pneumonia
- Klebsiella?
RF: Rare, elderly, ETOH, DM
Pulmonary features: cavitating pneumonia, especially upper lobes. Red-currant jelly sputum. May also cause an empyema
Management: Cefotaxime
Specific pneumonia
- Pseudomonas?
RF: Bronchiectasis, CF
Management: Taz
Specific pneumonia
- Mycoplasma
RF: epidemics
Prolonged onset.
Pulmonary features: Dry cough, reticulo-nodular shadowing or patchy consolidation
Extra-pulmonary
- Flu-like prodrome: headache/myalgia/arthralgia
- Known to cause immune-mediated neurological disease. May also cause paraesthesia or neuropathic pain.
- Haemolysis
Presents with erythema multiforme.
Cold agglutinins --> AIHA (Autoimmune haemolytic anaemia) Cryoglobulin Erythema multiforme SJS GBS Hepatitis
Diagnosis: Serology. X-ray shows bilateral consolidation on x-ray.
Typically does not respomd to penicillin or cephalosporin.
Treatment: Doxy/Clarithro/Cipro
Specific pneumonia
- Legionella?
RF: Travel, Air conditioning
Pulmonary Features: Dry Cough/Dyspnoea, bi-basal consolidation
Extra-pulmonary: flu-like prodrome, anorexia, D+V, hepatitis, renal failure, confusion, SIADH –> Decreased Na.
Management: lymphopenia, decreased Na, deranged LFTs.
Dx: urinary ag or serology
Clarithro ± rifampacin
Specific pneumonia
- Chlamydia pneumoniae?
Pulmonary Features: Pharyngitis, otitis –> pneumonia
Extrapulmonary: Sinus pain
Management: diagnosis with serology, then clarithromycin
Specific pneumonia
- Chlamydia psittica?
RF: Parrots
Pulmonary features: Dry cough, patchy consolidation
Extra-pulmonary: Horder’s spots ~ rose spots. Splenomegaly, epistaxis, hepatitis, nephritis, meningo-encephalitis.
Dx: serology then clarithro
Specific pneumonia
- PCP?
- Immunocompromised/HIV
- Pulmonary Features
Dry Cough, exertional dyspnoea, bilateral creps - CXR: normal or bilateral perihilar interstitial shadowing
Dx: Diagnosed from induced sputum - Visualisation from BAL, Sputus, biopsy
High dose co-trimoxazole or pentamidine
Prophylaxis if CD4 <200 or after 1st attack.
What is bronchiectasis?
- Permanent dilation of Bronchi due to destruction of the elastic and muscular components of the bronchial wall. Often causes as a consequence of recurrent and/or severe infections secondary to underlying disorder.
- Majority of patients will present with a chronic cough and sputum production.
- Retained inflammatory secretions and microbes –> airway damage + recurrent infection
- Because of H.influenza, pneumococcus, s.aureus, pseudomonas
Cause of bronchietasis
- Idiopathic in 50%
- Congenital
CF (mainly upper lobe infiltration)
Kartagener’s/PCD
Young’s syndrome (azoospermia + bronchiectasis). May also have dextrocardia. May also have recurrent sinusitis.
- Post-infectious
Measles, pertussis, pneumonia, TB, bronchiolitis
- Immunodeficiency Hypogammaglobulinaemia X-linked agammaglobulinaemia: Bruton's CVID IgG subclass deficiency IgA HIV
- Allergic bronchopulmonary aspergillosis
- Bronchial obstruction:
LNs, tumour, foreign body - Connective Tissue Disorders
RA
Sjogren’s - IBD
UC, Crohns
- Yellow nail syndrome Yellow nail discoloration and dystrophy Lymphoedema Pleural effusion Bronchiectasis
Symptoms of bronchiectasis?
Presence of RF: cystic fibrosis, immunodeficiency, previous infection, PCD, alpha-1 antitrypsin, IBD.
- Persistent cough with purulent sputum
- Haemoptysis
- Fever
- Weight loss
- Dyspnoea
Signs of bronchiectasis?
- Clubbing
- Coarse inspiratory crepitation/crackles - squeaks and pops
- Crackles
- Wheeze
- Purulent sputum
- Cause
Situs Inversus (+PCD = Kartagener’s syndrome)
Splenomegaly: immune deficiency
Complications of bronchiectasis?
- Pneumonia
- Pleural effusion
- Pneumothorax
- Pulmonary HTN
- Massive haemoptysis
- Cerebral abscess
- Amyloidosis
Investigations for bronchiectasis?
- Sputum MCS (gram-positive/gram-negative)
- Bloods:
FBC: WBC (eosinophil high = bronchopulmonary aspergillosis, neutrophilia may be infection)
NNO level in primary ciliary dyskinesia
Aspergillus precipitins,
RF,
a1-AT level
Test Ig response to pneumococcal vaccine - Sweat chloride test (abnormal test >60mmol/L CF is likely) ± CFTR protein gene mutation.
- CXR: thickened bronchial walls (tramlines and rings)
- Spirometry:
obstructive pattern (reduced FEV1, elevated RV/TLC) (obstructive = COPD, Asthma, Emphysema, bronchiectasis)
= Restrictive (FEV1 reduced, FVC reduced (FEV1/FVC ratio normal (>0.7). due to pulmonary fibrosis, pulmonary oedema, lobectomy, parenchymal lung tumours, guillian barre, myasthenia gravis, motor neuron disease, ARDS, Sarcoidosis)
- HRCT chest CT (High resolution) - thickened, dilated airways with/without air fluid levels. Cysts and/or tree-in-bud pattern.
- Bronchoscopy + mucosal biopsy:
Focal obstruction
PCD
Management of bronchiectasis?
- Chest physio: Expectoration, draining, pulmonary rehab (postural drainage, percussion, vibration).
- ABx for exacerbations: e.g cipro for 7-10days - Consider azithromycin for pseudomonas
- Bronchodilators: nebulised salbutamol/ipratroprium/tiotropium
- Inhaled hypertonic saline
- Treat underlying cause
CF: DNAase
ABPA: Steroids ±azole antifungal
Immune deficiency; IVIg
or Inhaled tobramycin/gentamicin - infected with pseudomonas. - Consider surgery for those with recurrent infections, severe haemoptysis or focal disease.
This can be resection of bronchiectatic area. or lung transplant in patients with FEV <30% or a rapid decline in FEV.
What is the pathogenesis of cystic fibrosis?
- Autosomal recessive
- Mutation of CFTR gene on Chr 7 (delta F508) (anion channel found in the apical membrane of epithelial cells)
- decrease luminal CL secretion and increase Na reabsorption –> Viscous secretions
- In sweat glands, decreased Cl and Na reabsorption –> salty sweat
Clinical features of cystic fibrosis in neonates?
- FTT (failure to thrive)
- Meconium ileus
- Rectal prolapse
Clinical features of cystic fibrosis in children/young adults - NOSE?
- Nose: nasal polyps, sinusitis
Clinical features of cystic fibrosis in children/young adults - Resp?
- Resp: cough (prolonged colds, coughing) , wheeze, recurrent infection, bronchiectasis, haemoptysis, pneumothorax, cor pulmonale
Clinical features of cystic fibrosis in children/young adults - GI + other?
GI
- Pancreatic insufficiency: DM, steatorrhoea, voracious appetite
- Distal intestinal obstruction syndrome
- Gallstones
- Cirrhosis (secondary to biliary obstruction)/ Splenomegaly
Other
- Male infertility, osteoporosis, vasculitis
- CLUBBING
Signs of Cystic fibrosis?
- Clubbing ± HPOA (hypertropic osteoarthropathy)
- Cyanosis
- Bilateral coarse crackles
Common respiratory organism in Cystic Fibrosis?
- Early
S.aureus
H.influenza
Late
- P.aeruginosa: 85%
- B.cepacia: 4%
Diagnosis of cystic fibrosis?
- Sweat test: Na and Cl >60mM
- Genetic screening for common mutations
- Faecal elastase (tests pancreatic exocrine function)
- Immunoreactive trypsinogen (neonatal screening)
Investigations of cystic fibrosis.
- Bloods: FBC, LFTs, Clotting, ADEK levels, glucose TT
- Sputum MCS
- CXR: bronchiectasis
- Abdo US: fatty liver, cirrhosis, pancreatitis
- Spirometry: obstructive defect
- Aspergillus serology/skin-test (20% develop ABPA)
Management of Cystic Fibrosis - General?
- MDT: Physician, GP, Physio, dietician, specialist nurse
- Neonate management?
lactulose to avoid obstruction.
Chest management for cystic fibrosis?
- Physio: postural drainage, forced expiratory techniques
- Abx: acute infections and prophylaxis (inhaled tobramycin or IV tobramycin/piptaz/ceftazatidime).
- Mucolytics: DNAse (dornase alfa + hypertonic saline inhaled.
- Bronchodilators (salbutamol in inhaler)
- Vaccinate
GI management for cystic fibrosis?
- Pancreatic enzyme replacement: pancreatin (Creon)
- ADEK supplements
Insulin - Urosdeoxycholic acid for impaired hepatic function (stimulates bile secretion) Oral bile acids.
- PPI or Antacid to produce more alkaline environent for pancreatic enzyme supplement.
Management of advanced lung disease in cystic fibrosis?
- O2
- Diuretics for cor pulmonale
- NIV
- Heart/lung transplantation
Other management requirements for cystic fibrosis?
- Management of complications: e.g DM
- Fertility and genetic counselling
- DEXA osteoporosis screen
What are the pulmonary aspergillus diseases?
- Asthma: T1HS reaction to spores
- ABPA
Hypersenstivity reaction to aspergillus antigens. Typically seen in patients with longstanding asthma - Aspergilloma (mycetoma
Intracavity mass in the lung consistent of massos of aspergillus mycelia. - Invasive aspergillosis
Local and systemic infiltration (in immunocompromised patients) - Extrinsic Allergic Alveolitis
What is Allergic Bronchopulmonary aspergillosis?
T1 and T3 HS reaction to Aspergillus fumigatus
- Bronchoconstricton –> Bronchiectasis
- Patients usually have a prior diagnosis of atopy, asthma or cystic fibrosis.
- Presents with broncial obstruction, airway inflammation leading to bronchiectasis, fibrosis and respiratory compromise.
Symptoms of ABPA?
- Wheeze (underlying asthma and bronchial hyperreactivity)
- Productive cough
- Dyspnoea
- Mucus plugs
RF: History of Asthma/CF
Investigations for ABPA?
- CXR: bronchiectasis (upper and middle lobe infiltrates)
- Aspergillus in sputum (black on silver stain)
- Aspergillus skin test of IgE RAST (positive wheal and flare reaction)
- Increased IgE and increased eosinophils
Management of ABPA?
- Pred 40mg/d + itraconazole for acute attacks (200mg)
- Environmental control
- Pred maintenance 5-10 mg/d
- Bronchodilators for asthma
What is an aspergilloma (mycetoma)
- Fungus ball within a pre-existing cavity (TB or sarcoid)
Features of aspergilloma?
Usually asymptomatic
Can –> Haemoptysis (may be severe)
Lethargy, decreased weight
Investigations for aspergilloma?
- CXR: round opacity within a cavity, usually apical
- Sputum culture
- Aspergillus skin test/RAST
Management of aspergilloma?
Consider exicision for solitary lesions/severe haemoptysis
What is invasive aspergillosis?
Causes by filamentous fungi of the Aspergillus species.
Aflatoxins –> Liver cirrhosis and HCC (especially A.flavus)
What are the risk factors for Invasive Aspergillosis?
Immunocompromise: HIV, leukaemia, Wegener’s
post-broad spectrum abx
Investigations of invasive aspergillosis?
- CXR: consolidation, abscess, cavities
- Sputum MCS - Aspergillus species
- BAL - show hypal elements or aspergillus
- Serial galactomannan (two positive results)
Management of Aspergillosis?
Voriconazole for confirmed or amphotericin B for suspected.
What is Extrinsic Allergic Alveolitis?
= Inflammation of alveoli and sital bronchiales caused by immune response to inhaled allergens.
- Occupational exposure to organic dust.
- Sensitivity to aspergillus clavatus –> Malt worker’s lung
- Bird fancier’s lung
- Famer’s lung: Saccharopolyspora rectivirgula
- Mushroom workers: thermophilic actinomycetes
Key points in a history for EAA? (as part of a hypersensitivty pneumonitis)
- Exposure to avian protein antigen
- Mould in work environment
- Occupational exposure to chemicals
- Productive/non-productive cough.
- Fevers, malaise, weight loss, diffuse rales, clubbing.
- Restrictive picture
- Chest x-ray: upper/mid-zone fibrosis
- Bronchoalveolar lavage: lymphocytosos
- NO eosinophilia
EAA management?
Corticosteroid taper + avoidance of antigen.
First line is avoidance, then corticosteroid avoidance.
Types of Lung Cancer?
Non-small cell - Squamous Cell Carcinoma (PTH - hypercalcaemia ,clubbing HPOA, hyperthyroidism. - Adenocarcinoma Gynaecomastia, HPOA. - Large cell carcinoma
Small cell Carcinoma (rapid presentation)
- ADH, ACTH, Lambert Eaton Syndrome
Epidemiology and behaviour of sqaumous cell carcinoma
35% of all LC.
M>F
Smoking + Radon Gas
Pathology
- Centrally located with evidence of squamous differentiation (keratinisatioN).
Behaviour
- Locally invasive + metastasis late (via LN)
- Release PTHrP –> increased Ca2+
Epidemiology and behaviour of adenocarcinoma?
25% of all LC
Females, non-smokers, far east.
Peripherally located
- Histo shows glandular differentiation (gland formation + mucin production).
- common extrathoracic mets and early.
- 80% presents with mets.
Epidemiology and behaviour of large cell carcinoma
10% - Peripheral or central
Large, poorly differentiated cells with a poor prognosis.
Epidemiology and behaviour of small cell carcinoma?
Central location near the bronchi
- Histo: poorly differentiated cells.
- 80% present with advanced disease. Very chemosensitive but v.poor prognosis. Ectopic hormone secretion.
- Rapid presentation + have paraneoplastic
What other lung tumours do you know?
- Adenoma: 90% are carcinoid tumours
- Hamartoma
- Mesothelioma
What is the epidemiology of all lung cancers?
19% of all cancers
27% of all cancer deaths
What are the symptoms of lung cancer?
- cough and haemoptysis. New or persistent cough in a current or former smoker.
- dyspnoea - Dyspnoea because of underlying COPD, pneumonia, or airway obstruction.
- Chest pain - Most patients with chest pain have tumours invading the pleura or chest wall.
- Recurrent or slow resolving pneumonia
- Anorexia and weight loss
- hoarseness due to recurrent laryngeal nerve palsy.
Signs in the chest of lung malignancy?
- Consolidation
- Collapse
- Pleural effusion
General signs of lung malignancy?
- Cachexia
- Anaemia
- Clubbing and HPOA (painful wrist swelling) more common in adenocarcinoma
- Supraclavicular and/or axillary LNs (Horner’s syndrome presenting with ptosis, miosis, ipsilateral anhydrosis)
Signs of metastasis
- Bone tenderness
- Hepatomegaly
- Confusion, fits, focal neuro
- Addison’s
- Cannon-ball mets = most commonly caused by renal cell cancer - CT abdomen is most appropriate to investigate this.
Complications of lung cancer - local?
- Recurrent laryngeal nerve palsy
- Phrenic nerve palsy
- SVC obstruction
- Horner’s (Pancoast tumour) common in NSCLC
- AF
Paraneoplastic complications of lung cancer endo?
Endocrinology - Mostly found on SCLC
- ADH –> SIADH (euvolaemic decreased in Na) due to small cell lung cancer.
- ACTH - Cushing’s syndrome
- Serotonin –> Carcinoid (flushing, diarrhoea)
- PTHrP –> primary HPT (increased Ca, bone pain) Mainly in squamous cell carcinoma.
Lambert-Eaton syndrome in SCLC - autoimmune attack on VGCC.
Paraneoplastic complications of lung cancer rheum?
Dermatomyositis/polymyositis
Paraneoplastic complications of lung cancer Neuro?
- Cerebellar degenerations (due to Purkinje cells
- Peripheral neuropathy
Paraneoplastic complications of lung cancer dermatology?
- Acanthosis nigricans (hyperpigmented body folds)
- Trousseau syndrome: thrombophlebitis migrans (pancreas and lung). vessel inflammation due to blood clots in different part of the body. May present with visually swollen vessels.
Metastatic complications of lung cancer?
- Pathological features
- Hepatic failure
- Confusion, fits, focal neurology
- Addison’s disease
Investigations for Lung cancer - blood and sputum?
Bloods: FBC (anaemia) , U+E (SIADH + hyponatraemia) , Ca2+ (squamous cell carcinoma), LFTs (metastases)
Cytology: Sputum (malignant cells in sputum), pleural fluid (patients that present a pleural effusion so would want to sample to look for malignant cells)
Lung function tests
- Assess treatment fitness?
Imaging for lung cancer?
Offer urgent X-ray (2 weeks) to assess for lung cancer in people 40 or over with 2 or more unexplained symptoms (cough, fatigue, SOB, chest pain, weight loss, appetite loss).
CXR
- coin lesions
- Hilar enlargement
- Consolidation, collapse
- effusion
- bony secondaries
- Contrast-enhanced volumetric CT (neck, thorax + upper abdo)
Useful for staging, shows location + extent of primary tumour and evaluates hilar/mediastinal lymphadenopathy + distant mets.
Consider
- PET-CT: Exclude distant mets
- Radionucleotide bone scan
Types of biopsy for lung cancer?
- Percutaneous FNA: peripheral lesions and LN
- Bronchoscopy: biopsy and assess operability
- Endoscopic bronchial US biopsy: mediastinal LNs
What are the differentials for a CXR coin lesion?
FANGS
- Foreign body
- Abscess: Staph, TB, Klebsiella, Mycetoma
- Neoplasia (primary or secondary)
- Granuloma: RA, Wegener’s, TB, Sarcoid
- Structural, AVM
What is the staging for a non-small cell lung carcinoma?
TNM staging
- Tx = Malignancy cells in bronchial secretions
- Tis = CIS (carcinoma in situa)
- T0 = None evidence
- T1 = <3cm in lobar or more distal airways
- T2 = >=3cm and >2cm from carina or pleural involvement
- T3 = <2cm from carina or involves chest wall, diaphragm or >1 tumour in same lobe of lung
- T4 = Involves mediastinum or malignant effusion in present, or more than 1 lobe.
N0 = none involved N1 = Peribronchial or ipsilateral hilum N2 = Ipsilateral mediastinum N3 = contralateral hilum or mediastinum or supraclavicular
General management of lung cancer?
Refer using suspected 2ww
- If they have chest x-ray finding suggesting lung cancer
- Age 40 and over with unexplained haemoptysis.
MDT: Respiratory physician, oncologist, radiology, histopathologist, specialist nurse, palliative care, GP.
Assess risk of operative mortality: Thoracoscore + cardioresp function + comorbidities
Advise smoking cessation
NSCLC management?
Contra-indications to surgery
- Stage IIIb or IV (mets)
- FEV1 <1.5 litres considered general cut-off
- Malignant pleural effusion
- Tumour near hilum
- Vocal cord paralysis
- SVC obstruction
Surgical resection
- Management of choice for peripheral lesions with no metastatic spread = Stage I/II (~25%)
- Requires good cardiorespiratory function
- Wedge resection, lobectomy or pneumonectomy
± adjuvant chemo (cisplatin-based) preoperatively for stage II) and post-operatively for Stage 1B and 11.
If not suitable use radiotherapy - if cardioresp reserve is poor.
Chemo±radi for more advanced disease
- Platinum-based regimes
- If N2 or less consider surgery.
For palliative: Consider MAbs targeting EGFR (cetuximab) or nintedanib (TKI), bevacizumab, ramucirumab (VEGFR) , pembrolizumab (programmed death-1 receptor)
Management of SCLC?
- Typically disseminated @ presentation
- May respond to chemo but invariably relapses therefore use cisplatin + radiotherapy
Management of palliation in SCLC?
- Radiotherapy: bronchial obstruction, haemoptysis, bone or CNS mets
- SVC obstruction: stenting + Radio + dexamethasone
- Endobronchial therapy: -Stenting, brachytherapy (radioactive material inside body)
- Pleural drainage
- Analgesia
Prognosis of Lung malignancy?
SCLC 5 yr = 12% to 24%
NSCLC 5 yr = Stage 1 = 67%, Stage 3 = 23/25%.
What is the pathogenesis of ARDS?
- May result from direct pulmonary insult or be secondary to sever systemic illness.
- Non-cardiogenic pulmonary oedema and diffuse lung inflammation syndrome that often complicates critical illness
- Inflammatory mediators –> increased capillary permeability and non-cardiogenic pulmonary oedema.
Clinical features of ARDS?
Tachypnoea Cyanosis Bilateral fine creps SIRS/Sepsis Fever/cough/pleuritic chest pain
Rx: sepsis, aspiration, severe trauma etc
Investigations for ARDS?
Bloods: ABG (low partial oxygen pressure PaO2/FiO2 inspired oxygen ratio of <300 on PEEP), sputum culture (sepsis), blood culture for sepsis, amylase/lipase for pancreatitis
CXR: Bilateral opacities not explained by effusion or collapse.
Diagnosis of ARDS?
- Acute onset
- CXR shows bilateral opacities/infiltrates
- No evidence of CCF
- PaO2:FiO2 200 -300 = Mild
100-200 = Moderate
<100 = Severe
CLinical indicated of hypoxaemia as it is comparing inspired oxygen to arterial oxygen
Management of ARDS?
- Admit to ITU for organ support and manage underlying cause
Ventilation
- Indications
PaO2 <8kPa (normal is >10.6) despite 60% FiO2
- PaCO2 >6KPa
Method
- 4-8ml/kg + PEEP (e.g 10cm H20)
- SE = VILI (ventilator induced lung injury), VAP (pneumonia), Weaning difficulty
Circulation
- Invasive BP monitoring
- Maintain CO and DO2 with inotropes. Keep CVP <4cm H20.
- Dobutamine
Sepsis = Abs
Causes of ARDS?
Pulmonary (alveolar damage + diffuse oedema)
- Pneumonia
- Aspiration
- Inhalation injury
- Contusion
Systemic
- Shock
- Sepsis
- trauma
- Haemorrhage
- Pancreatitis
- Acute liver failure
- DIC
- Obs: Eclampsia, amniotic embolism
- Drugs: aspirin or heroin
What is a differential diagnosis of pulmonary effusion?
- Transudate = Forced through by hydrostatic pressure therefore low protein. Therefore ratio is high (SAAG = >1.2)
- Exudate = Through inflammation therefore high protein. Therefore ratio is low as normal to blood (SAAG <1.2).
Causes of Transudates?
Increased capillary hydrostatic pressure
- CCF
- Iatrogenic fluid overload
- Renal failure
- Relative high in negative pressure pulmonary oedema
Decreased capillary oncotic pressure (opposite effect to hydrostatic, due to low protein levels)
- Liver failure
- Nephrotic syndrome
- Malnutrition, malabsorption, protein-losing enteropathy
Increased interstitial pressure
- Decreased lymphatic drainage: e.d Ca
Exudates
- ARDS
Define Type 1 Respiratory failure?
- PaO2 <8kPa and PaCo2 <6KPa (due to hypoxaemia)
V/Q mismatch and diffusion failure
Define Type 2 Respiratory Failure?
- PaO2 <8kPa and PaCO2 >6KPa
- Alveolar hypoventilation ± V/Q mismatch.
Causes of a V/Q mismatch and diffusion failure?
Either no oxygen or no blood to carry oxygen. Increased Alveolar-arterial gradient.
- Vascular due to PE (ventilation good but perfusion bad) PHT Pulmonary Shunt (R--> L) (perfusion problem) - Early Asthma - Pneumothorax - Atelectasis
Diffusion failure - Fluid Pulmomnary oedema Pneumonia Infarction Blood
Fibrosis (both fluid and fibrosis can also cause alveolar hypoventilation and V/Q mismatch due to decreased compliance.
Causes of alveolar hypoventilation therefore limit exchange of CO2 with atmosphere.
Obstructive
- COPD
- Asthma
- Bronchiectasis
- Bronchiolitis
- Intra and Extra-thoracic (Ca, LN, epiglottitis)
Restrictive
- Decreased drive: CNS sedation, trauma, tumour
- NM disease: cervical cord lesion, polio, GBS, MG
- Chest: kyphoscoliosis, obesity
- Fluid and fibrosis
Clinical features of hypoxia?
Acute
- Dyspnoea
- Tachypnoea
- Stridor
- Cyanosis
- Confusion
- Agitation
Chronic
- Polycythaemia
- PHT
- cor pulmonale (increase in HR)
Clinical features of hypercapnoea?
- Headache
- Flushing and peripheral vasodilatation
- Bounding pulse
- Flap
- Confusion –> Coma
Management of Type 1?
Give O2 and maintain SpO2 94-98%
Assisted ventilation if PaO2 <8Kpa despite 60%
Management of Type 2?
Controlled O2 therapy @24% oxygen aiming for SpO2 88-92%.
Check ABG after 20 mins
- If PaCO2 steady or lower can increased FiO2 if necessary
- If PaCO2 increased >1.5KPa and patient still hypoxic, consider NIV or respiratory stimulant.
- BiPAP can be helpful in hypercapnic.
Principles of oxygen therapy?
- Critically ill patients should receive high conc O2 immediately.
- O2 should be prescribed to achieve target SpO2.
94-98% for most patients
88-92% for those at risk of hypercapnic resp failure - In patients at risk of hypercapnic resp failure
- Start O2 therapy at 25% and do an ABG
- Blue Venturi @2-4L
Clinically: decreased RR with O2 may be useful sign
If PCO2 <6: increased target SpO2 to 94-98%
If PCO2 >6kPa: maintain target SpO2.
