Respiratory Conditions Flashcards
1
Q
What are the characteristics of asthma?
A
- chronic inflammation of the airways
- Causes reversible airway obstruction either spontaneously or with treatment
- There is increased airway narrowing to a variety of stimuli
2
Q
What are the differentials for wheeze?
A
- Acute asthma exacerbation
- Bronchitis (viral or bacterial)
3
Q
Describe the pathophysiology of asthma
A
- Airway epithelial damage - shedding and subepithelial fibrosis with basement membrane thickening
- An inflammatory reaction characterised by eosinophils, T-lymphocytes (Th2) and mast celss
- Inflammatory mediators: histamine, leukotrienes and prostaglanins
- Cytokines amplify inflammatory response
- Increased number of mucus secreting goblet cells with smooth muscle hyperplasia and hypertrophy
- Mucus plugging in fatal and severe asthma
4
Q
What is the criteria for safe discharge after an asthma exacerbation?
A
- PEFR >75%
- Stop regular nebulised for 24 hours prior to discharge
- Inpatient asthma nurse review to assess inhaler technique and adherance
- Provide PEFR meter and written asthma action plan
- At least 5 days of oral prednisolone
- GP to follow up within 2 working days
- Respiratory clinic follow up within 4 weeks
- For severe or worse, consider psychosocial factors
5
Q
What is eospinophilic asthma?
A
Some asthma patients have eosinophilic inflammation which typically responds to steroids
6
Q
Apart from asthma, what are some other causes of eosinophilia?
A
- Airway inflammation (COPD)
- Hayfever/ allergy
- Allergic bronchopulmonary aspergillosis
- Drugs
- Churg-Strauss / Vasculitis
- Eosinophilic Pneumonia
- Parasites
- Lymphoma
- SLE
- Hyperoeosinphilic syndrome
7
Q
What are some of the triggers for asthma?
A
- Smoking
- URTI (mainly viral)
- Allergens (polle, dust mite, pets)
- Exercise
- Cold air
- Occupational irritants
- Pollution
- Drugs - beta blockers (including eye drops!), aspirin
- Food and drink: dairy, alcohol, orange juice
- Stress
- If very severe : consider causes as heroin, pre-menstrual, psychosocial
8
Q
What is the NICE definition of COPD?
A
Airflow obstruction that is usually progressive, not fully reversible and does not change markedly over several months
9
Q
What is the pathophysiology behind COPD?
A
Umbrella term encompasses emphysema and chronic bronchitis
There is:
- Mucus gland hyperplasia
- Loss of cilial function
- Alveolar wall destruction causing enlargement of air spaces distal to terminal bronchiole
- Chronic inflammation and fibrosis of small airways
10
Q
What are the main causes of COPD?
A
- Smoking
- alpha - 1 antitrypsin deficiency
- Industrial exposure e.g. soot
11
Q
How is COPD managed as an outpatient?
A
COPD care bundle
- SMOKING CESSATION
- Pulmonary rehabilitation
- Bronchodilators
- Antimuscarinics
- Steroids
- Mucolytics
- Diet
- LTOT if appropriate
- Lung volume reduction if appropriate
12
Q
What is the benefit of LTOT in COPD patients?
A
- Extended hypoxia can cause renal and cardiac damage
- Continuous o2 for at least 16 hours per day has a survival benefit
- only offered if pO2 is persistantly <7.3kPa or below 8kPa with Cor Pulmonale
- Patient must be non-smoker and not retain high CO2 levels
13
Q
How should patients who have had pneumonia be followed up?
A
- HIV test
- Immunoglobins
- Penumococcal IgG serotying
- Haemophilus influenza b IgG
- Follow up in clinic in 6 weeks with repeat CXR to ensure resolution
14
Q
What are some of the causes of non-resolving pneumonia?
A
CHAOS
- Complication - lung abscess, empyema
- Host - immunocompromised
- Antibiotics - inadeqaute dose, poor oral absorption
- Organism - resistant or unexpected organism not covered by empirical abx
- Second diagnosis - PE, cancer, organising pneumonia
15
Q
What are some of the clinical features of TB?
A
- Fever
- Night sweats (drenching)
- Weight loss over weeks-months
- Malaise
- Respiratory TB: cough +/- purulent sputum, haemoptysis, may have pleural effusion
- Non respiratory TB: skin (eythema nodosum), lymphadenopathy, bone/joints, CNS (meningitis), GU, Miliary (disseminated), Cardiac (pericardiacl effusion)
16
Q
What are some of the differentials of haemoptysis?
A
-
Infection
- Pneumonia
- TB
- Bronchiectasis/ CF
- Cavitating lung lesion (often fungal)
-
Malignancy
- lung cancer or metastasis
-
Haemorrhage
- bronchial artery erosion
- vasculitis
- coagulopathy
- Others: PE
17
Q
Describe the basics of anti-TB therapy
A
RIPE is standard regimen
Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
All Taken for the first 2 months then only Rifampicin for next 4 months (minimum 6 months total)
- weight is important - dose is weight dependent
- Need to check baseline LFTs and monitor closely
- Check visual acuity before giving ethambutol
- Compliance is crucial - directly observed therapy is sometimes used
18
Q
What are some of the major side effects of TB treatment?
A
- Rifampicin: Hepatitis, rashes, febrile reaction, orange/ red urine or tears, many drug interactions
- Isoniazid: Hepatitis, rashes, peripheral neuropathy, psychosis
- Pyrazinamide: Hepatitis, vomiting, rashes, arthralgia
- Ethambutol: Retrobulbar neuritis
19
Q
What is bronchiectasis?
A
Chronic dilatation of one or more bronchi
Bronchi experience poor mucus clearance and therefore prone to recurrent bacteral infections
20
Q
What is the gold standard investigation for bronchiectasis? What is a classic finding?
A
High resolution CT
Signet ring sign (bronchi are wider than their corresponding arteries)
21
Q
What are some of the causes of bronchiectasis?
A
- Post infective: whooping cough, TB
- Immune deficiency: Hypogammaglobinaemia
- Genetic / Mucociliary clearance deficits: CF, primary cilliary dyskinesia, Young’s sydrome, Kartagener syndrome
- Obstruction: foreign body, tumour, extrinsic lymph node
- Toxic insult: gastric aspiration, inhalation of toxic chemicals/ gasses
- Allergic bronchopulmonary aspergillosis
- Secondary immune deficiency: HIV, malignancy
- RA
22
Q
What common organisms are seen in bronchiectasis?
A
- Haemophilus influenxae
- Pseudomonas aeruginosa
- Moraxella catarrhalis
- funghi - aspergillus, candida
- non-tb mycobacteria
23
Q
How is bronchiectasis managed?
A
- Treat the underlying cause
- Chest physio
- Abx according to sputum culture
- Supportive measures
- flu vaccine
- bronchodilators
- Pulmonary rehab if MRC dyspnoea score >3
24
Q
Describe the MRC dyspnoea scale
A
25
What is cystic fibrosis?
**Autosomal recessive** disease leading to mutations in CFTR channel causing **multisystemic disease** commonly affective the respiratory and GI systems
It is characterised by **thickened secretions**
26
How is a diagnosis of CF made?
* 1 or more characteristic phenotypic features
* Hx of CF in sibling
* + newborn screen
* Increased **sweat chloride concentration \>60mmol/L**
* identification of 2 CF mutations on genotyping
* abnormal nasal epithethelial ion transport
27
How can CF present?
* **Meconium ileus**
* 15-20% newborn CF patients as the bowel is blocked by sticky secretions
* signs of intestinal obstruction soon after birth: vomiting, abdominal distension, delay in passing meconium
* **Intestinal malabsorption**
* Evident in infancy due to severe deficiency of **pancreatic enzymes**
* **Recurrent chest infections**
* **Newborn screening**
28
What are some of the complications of CF?
* Respiratory infections
* Low body weight
* Distal intestinal obstruction syndrome
* CF related diabetes
29
What lifestyle advice do you give to CF patients?
* No smoking
* Avoid other patients who have CF
* Avoid friends/ relatives with colds/ infections
* Avoid jacuzzis (pseudomonas)
* Clean and dry nebulisers thoroughly
* Avoid stables, compost or rotting vegetation = aspergillus risk
* Get annual influenza immunisation
* Take sodium chloride tablets in hot weather / after vigorous exercise
30
What is the pleural cavity?
A **potential space** between 2 pleural spaces creased by the outer **parietal pleura** and the inner **visceral pleura**
31
What is pneumothorax?
Air in the pleural cavity
32
What is a pleural effusion?
Fluid in the pleural cavity
33
What is am empyema?
Infected fluid in the pleural cavity
34
What are pleural plaques?
Discrete fibrous areas on the pleura
35
What are the types of pneumothorax?
1. **Spontaneous**
1. Primary (no lung disease)
2. Secondary (lung disease)
2. **Traumatic**
3. **Tension (emergency)**
4. **Iatrogenic** (post central line or pacemaker insertion)
36
Give some risk factors for developing a pneumothorax?
* Pre-existing lung disease
* Tall
* Smoking/ cannabis
* Diving
* Trauma/ Chest procedure
* Associated with other conditions e.g, Marfan's
37
How should pneumothoraxs be managed?
* **Aspirate** if symptomatic and rim of air \>2cm on CXR
* Give O2
* If aspitation unsucussful consider re-aspiration or intercostal drain
* If peristent air leak \>5 days refer to thoracic surgeons
38
What is a tension pneumothorax?
39
What initial investigations are done if suspecting pleural effusion?
* History and examination
* CXR
* ECG
* Bloods: FBC, U&E, LFTs, CRP, Bone profile, LDH, clotting
* ECHO is suspecting HF
* Staging- CT with contrast if suspecting exudate cause
40
How is a diagnosis of pleural effusion made?
**Ultrasound guided pleural aspiration**
Send aspirate for biochemisty (protein, pH, LDH), cytology, microbiology
41
Which criteria is used to determine whether a pleural effusion is transudate or exudate?
**LIGHT's criteria**
42
Give some of the causes of transudate pleural effusions (pleural protein \<30 g/L)
**Common**
* HF
* Cirrhosis
* Hypoalbuminaemia (nephrotic syndrome or peritoneal dialysis)
**Less common**
* Hypothyroidism
* Mitral stenosis
* PE
* **RARE:** constrictive pericarditis, SVC obstruction
43
Give some of the causes of **exudate** pleural effusions
**Common:**
* Malignancy
* Infections - parapneumonic, TB, HIV
**Less common:**
* Inflammatory: (RA, pancreatitis, benign asbestos effusion)
* Lymphatic disorders
* Connective tissue disorders
**Rare:**
* Yellow nail syndrome, fungal infections, drugs
44
How are pleural effusions managed?
* **Treat the underlying cause** (if known)
* diagnostic tap is not always required
* If effusion perists, therapeutic aspitation/ draininge is required
45
What is interstitial lung disase?
A collection of conditions that affect the lung **parenchyma**
includes: usual interstitial pneumonia, non-specific intersistial pneumonia, extrinsic allergic alveolitis, sarcoidosis
46
Give some of the classical findings of usual interstitial pneumonia (commonest form of pulmonary fibrosis)
* Finger clubbing
* Reduced chest expansion
* **Auscultation:** fine inspiritory crepitations best hear at basal/ axillar areas
* **Cardiovascular:** features of pulmonary hypertension
47
What is extrinsic allergic alveolitis?
Also known as hypersensitivity pneumonia
**Inhalation** of an organis antigen to which the individual has been **sensitised**
**Acute:** short period from exposure (4-8hours) usually reversible
**Chronic:** chronic exposure over months - years. less revsersible
48
What is sarcoidosis?
A multisystem **inflammatory** condition of unknown cause
* causes **non-caseating granulomas**
* Commonly involves respiratory system but can affect all organs
* 50% get spontaneous remission, 50% get progressive disease
49
What investigations should be done if suspecting sarcoidosis?
* Pulmonary function tests
* CXR
* Bloods: renal function, Calcium
* Urinary calcium
* Cardiac: ECG, 24hr tape, ECHO, cardiac MRI
* CT/MRI head if headaches- neuro sarcoid
50
Give some risk factors for lung cancer
* Smoking - large number of pack years
* Airflow obstruction
* increasing age
* FHx of lung cancer
* Exposure to other carcinogens (asbestos)
51
Give some of the clinical features/ presentations of lung cancer
* Asymptomatic (incidental finding)
* Respiratory problems/ systemic deterioration
* Superior Vena Cava Obstruction
* Horner's syndrome
* Metastatic disease, liver, adrenals, bone, pleura, CNS
* Clubbing
* Hypercalcaemia
* Anaemia
52
What investigations should be done if suspecting lung cancer?
* Bloods: FBC, U&E, Ca2+, LFTs, INR
* CXR
* Staging CT
* **Histology:** USS guided neck node biopsy, CT biopsy, bronchoscopy, thoracoscopy (if pleural effusion present)
* PET scan
53
What are the 2 main histological groups of lung cancer?
1. Small cell lung cancer
2. Non-small cell lung cancer
1. includes squamous cell, adenocarcinoma, large cell carcinoma, bronchoalveolar
54
Summaries the treatmen options for lung cancer
* Stage I and II can have curative surgery
* Surgery & adjuvant chemotherapy in clinical trial for stage 3a
* Chemotherapy if patients stage 3/4
* Radiotherapy can be curative or palliative
* Palliative care
55
What is obstructive sleep apnoea?
**Upper airway narrowing** provoked by **sleep** can cause sufficient sleep fragmentation and result in significant **daytime symtpoms** and exessive sleepiness
56
What are some of the risk factors for obstructive sleep apnoea?
* Male
* Obesity
* Undersized/ set back mandible
57
Describe the pathophysiology behind obstructive sleep apnoea
* For the upper airway to stay patent it depends on **dilator muscle** - **all muscles relax during sleep**
* Some narrowing of the upperairway is normal
* **excessive narrowing** is due to already small pharyngeal size or excessive relaxation during sleep
58
What can cause small pharyngeal size leading to OSA?
* Fatty infiltration of pharyngeal tissues
* External pressure from increase neck fat/ muscle bulk
* Large tonsils
* Craniofacial abnormalities
* Extra submucosal tissue e.g. myxoedema
59
What are some of the causes of excessive airway narrowing during sleep?
* **Obesity** - enchances residual muscle dilator action
* **Neuromuscular disease**
* **Muscle relaxants** - sedatives, alcohol
* **Increasing age**
60
What are some of the effects of OSA?
* Repeated upper airway collapse causes associated **hypoxia** and **hypercapnia**
* Unrefreshed sleep
* Snoring and apnoea witnessed by partner
* Excessive daytime sleepiness
* Rise in BP
* Nocturia
* Nocturnal sweating
* Reduced Libido
61
Which criteria is used to assess daytime sleepiness in OSA?
**Epworth Sleepiness Scale**
62
How is OSA diagnosed?
* Overnight oximetry
* Limited sleep study
* Full polysomnography
63
How is OSA managed?
Treatment given based on QoL, not the sleepines score
**Conservative:**
* Weight loss
* Sleep on the side rather than supine
* Avoid evening alcohol
**For snorers:**
* Mandibular advancement devices
* Pharyngeal surgery a last resort
**For significant OSA:**
* Nasal CPAP
* Gastric bypass
* Tracheostomy (rare!)
64
What advice should you give patients with OSA about driving?
* Do not drive whilst sleepy - stop and have a nap
* Patient should notify DVLA on diagnosis
* Advise HGV drivers to stop all together
65
What is the difference between CPAP and NIV
**CPAP** = **continuous positive airway pressure**
* not a form of ventilatory support
* supplies constant pressure in inspiration and expiration
**NIV= non invasive ventilatory support**
* **does** provide ventilatory support
* set at 2 levels (bilevel) of pressure
