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Respiratory Disease > Respiratory Disease > Flashcards

Respiratory Disease Flashcards

1
Q

Asthma: Definiton

A

Chronic inflammatory condition associated with airway inflammation and hyper-responsiveness leading to reversible bronchial constriction.

> > childhood asthma, adult-onset asthma, exercise induced asthma, occupational asthma

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2
Q

Asthma: Epidemiology

A

8 million diagnosed with asthma in UK
5.4 million on asthma treatment
3 deaths per day due to asthma attacks
£1.1 billion on asthma each year

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3
Q

Asthma: Pathophysiology

A

> > exposure to irritants: cold air, exercise, smoke, pollution, allergen, medications
triggers type 1 hypersensitivity reaction mediated by IgE
T-helper 2 cells produce interleukins and cytokines
proliferation and recruitment of mast cells, eosinophils, goblet cells, neutrophils
these cells produce more inflammatory mediators&raquo_space; MAST CELLS: leukotrines, histamine, prostaglandins
goblet cells cause mucus hypersecretion

> > airflow obstruction&raquo_space; mucus, inflammation
broncho-hyperesponsiveness&raquo_space; exaggerated broncho-constriction
inflammation
airway remodelling&raquo_space; fibrotic and thickened smooth muscle

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4
Q

Asthma: Risk Factors

A

Genetic:
» gender
» atopy: eczema, hay-fever, allergic rhinitis

Environmental:
» exposure to allergens
» smoking
» exposure to animals
» socio-economic status

Other:
» stress
» medication
» diet and nutrition
» prenatal smoking
» recurrent respiratory infections
» occupation

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5
Q

Asthma: Symptoms

A

Wheeze
Chest tightness
Cough
Dysponea
Decreased exercise tolerance

All symptoms typically diurnal&raquo_space; symptoms worse at night

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6
Q

Asthma: Signs

A

Between sthma exacerbations, clinical examination may be normal.

Tachypnoea
Use of accessory muscles
Polyphonic wheeze&raquo_space; lots of different pitched noises
Hyperinflated chest
Hyper-resonant percussion note

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7
Q

Asthma: Diagnosis

A

History + examination + investigation

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8
Q

Asthma: Investigations

A

Spirometry-
» offered to all over 5 years
» blow into device as hard, fast, long as patient can
» FEV1/FEV ratio less than 70% = confirms airway obstruction
» then, do Bronchodilator Reversibility (BDR)&raquo_space; give bronchodilator and do spirometry again
» if increase of over 12% in FEV1 and 200ml increase in FEV1 = positive result = diagnosable asthma

Fractional exhaled nitrix oxide testing (FeNO)-
» offered to all adults
» NO levels high in asthma patients due to eosinophilic inflammation
» a reading of over 40 part per billion (ppb) = positive
» if FeNO is positive = suggestive of asthma

Peak Expiratory Flow (PEF)-
» offered to all adults
» blow into device as hard and as fast as patient can
» peak flow diary 2x daily for 2-4 weeks
» over 20% variability between highest and lowest result = suggestive and diagnostic for asthma

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9
Q

Asthma: Extra Investigations

A

Respiratory exam: confirm symptoms and signs
CVS exam: rule out other causes of symptoms
ENT exam: polyps
X-ray
FBC: inflammatory cells
Sputum sample

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10
Q

Asthma: Investigations for Children

A

Children under 5 years-
» can’t perform objective testing
» use clinical judgement, signs and symptoms, and any positive results

Spirometery: 5-16yrs = FEV1 of 12% or more is positive
FeNO: 5-16yrs = result of 35ppb is positive
PEF: 20% variability is positive

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11
Q

Asthma: Management for Adults

A

For adults 17+
For young adults 5-16&raquo_space; same but paediatric dose of ICS
GIVE SPACER FOR INHALERS

STEP 1: Prescribe an inhaled short-acting β2 agonist (SABA)as reliever therapy&raquo_space; salbutamol, salamol, aeromir
STEP 2: Prescribe an inhaled corticosteroid (ICS) as preventer therapy&raquo_space; clenil
STEP 3: Leukotriene receptor antagonists (LTRAs) orally as first-line add-on treatment to low dose ICS in adults&raquo_space; montelukast
» recommended 4-8week trial period before LABA
STEP 4: Offer a long-acting beta-2 agonist (LABA) in combination with the ICS&raquo_space; never LABA without ICS as risk of death
» no need to continue LTRA if not useful&raquo_space; use clinical judgement
STEP 5: If still uncontrolled start MART treatment plan: fast onset LABA and ICS&raquo_space; symbicort and fostair
» MART: maintenance and reliever therapy
STEP 6: MART plan: fast onset LABA with high dose ICS

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12
Q

Asthma: Stepping Up and Down

A

Asthma action plan&raquo_space; (1) everyday asthma plan (2) when I feel worse (3) In an asthma attack
Review asthma plan yearly
Review patient after 6 months of changing treatment

If reliever inhaler needed more than 3 times per week&raquo_space; poor management STEP UP NEEDED

USE ASTHMA CONTROL TEST
NICE guidline on complete control over asthma:
» no daytime symptoms due to asthma
» no limitations on daily activities due to asthma
» no night waking due to asthma
» no reliever needed

If complete control for minimum 3 months, consider STEP DOWN treatment
» aim for lowest step
» when reducing ICS, drop 25-50% every 3 months

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13
Q

Asthma: Management for Children

A

For children under 5 years

STEP 1: offer SABA for suspected asthma as reliever
STEP 2: consider 8-week trial for paediatric dose of ICS
STEP 3: after 8-weeks stop ICS treatment monitor
» if symptoms DON’T resolve, review diagnosis
» if symptoms DO resolve, but symptoms recur within 4 weeks of stopping, restart paediatric-dose ICS treatment for maintenance therapy
» if symptoms DO resolve, but symptoms recur after 4 weeks of stopping, repeat 4 week ICS trial period

STEP 4: addition of LTRA that are authorised for children
STEP 5: REFER

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14
Q

Acute Asthma: Definition

A

Acute severe asthma is an acute exacerbation of asthma that does not respond to standard treatments

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15
Q

Acute Asthma: Severity

A

Moderate-
» increasing symptoms
» PEFR > 50% of predicted or best
» no features of severe/life-threatening asthma

Severe-
» PEFR 33-50% of predicted or best
» heart rate > 110/min
» respiratory rate > 25/min
» unable to complete sentences in one breath.
» accessory muscle use

Life-threatening-
» PEFR < 33% of predicted or best
» Oxygen saturation < 92% or cyanosis
» normal PaCO2
» altered conciousness/confusion
» exhaustion
» poor respiratory effort
» hypotension
» silent chest

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16
Q

Acute Asthma: Risk Factors

A

Previous ITU admissions
Far along treatment steps

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17
Q

Acute Asthma: Investigations

A

PEFR: to help classify severity
Chest X-ray: exclude pneumothorax or consolidation
FBC : find cause
CRP: C-reactive protein is produced by the liver&raquo_space; indicates inflammation in the body
ABG: check PaO2 and PaCO2
» if PaCO2 is normal = life threatening
» if PaCO2 is raised = near fatal

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18
Q

Acute Asthma: Management

A

IMMEDIATELY ADMIT
» oxygen, SABA, steroids

> > ABCDE assessment
oxygen to maintain saturations of 94-98%
SABA: 4 puffs initially, 2 puff every 2 minutes, upto 10 puffs OR nebulised SABA
steroids: oral prednisolone or IV hydrocortisone

> > nebulised ipratropium bromide&raquo_space; SAMA
consider IV magnesium sulphate if patient not responding&raquo_space; magnesium is CCB and causes bronchiodilation

ITU if no improvement
May require intubation and mechanical ventilation

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19
Q

Acute Asthma: Follow Up

A

Notify primary care within 24 hours
Follow up within 2 days of discharge
Check obs and peak flow
Address preventable contributors&raquo_space; vaccines, smoking, mould
Ensure written plan
Set up regular therapy, as needed

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20
Q

Smoking Cessation

A

ENCOURAGE ALL PATIENTS TO STOP SMOKING
» stopping smoking can prevent 15 types of cancers
» smokers require higher doses of ICS for prevention

Pharmacological treatments-
» nicotine replacement therapies: nicotine patches, lozenge, chewing gum&raquo_space; CANNOT CONTINUE SMOKING
» varenicline (champix): blocks nicotine receptors in brain, 12 week course, over 18 and not pregnant or breast feeding&raquo_space; CAN CONTINUE SMOKING
» bupropion

Non-pharmacological treatments-
» vaping
» community support
» therapy and counselling

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21
Q

Acute Bronchitis: Definition

A

Inflammation of the bronchioles and mucus secretion

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22
Q

Acute Bronchitis: Pathophysiology

A

Commonly viral: influenza, rhinovirus, RSV
Sometimes bacterial

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23
Q

Acute Bronchitis: Risk Factors

A

Smoking
Damp or dusty environment

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24
Q

Acute Bronchitis: Symptoms

A

Healthy person with cough&raquo_space; lasts 7-10 days but can persist upto 3 weeks
Pleuritic or retrosternal pain
Fever
Headache

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25
Q

Acute Bronchitis: Signs

A

Often no clinical signs
» coarse crepitations, wheeze

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26
Q

Acute Bronchitis: Management

A

Resolved by itself-
» resolution typically 3 weeks
» analgesia, fluids, smoking cessation, rest
» typically no antibiotics because usually caused by viral infection
» consider delayed antibiotic with advice

Immediate antibiotic if-
» over 80 with ONE of: hospitilisation within past year, heart failure, oral steroids, diabetic
» over 65 with TWO of: hospitilisation within past year, heart failure, oral steroids, diabetic
» prescribe amoxicillin 500mg, 3x per day

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27
Q

Influenza: Definition

A

Influenza or ‘flu’ is a single-stranded RNA virus causing URTI

Typically self-limiting&raquo_space; resolves by itself without medical intervention
» can cause mortality in patients with co-morbidities

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28
Q

Influenza: Epidemiology

A

Three serotypes: A, B, and C
» A and B respnsible for epidemic respiratory infections
» seasonal influenza caused by mix of A and B

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29
Q

Influenza: Pathophysiology

A

Viral: highly contagious, and transmitted by respiratory secretions

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30
Q

Influenza: Symptoms and Signs

A

Incubation period is typically 1–4 days
Patients can remain infectious for 7–21 days

Fever ≥ 37.8°C
Nonproductive cough
Myalgia
Headache
Malaise
Sore throat
Rhinitis

Infants and children: fatigue, irritability, diarrhoea, vomitting

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31
Q

Influenza: Management

A

Self-limiting disease

Fever, myalgia, headache&raquo_space; paracetamol, ibuprofen

Fluids
Rest
Avoid smoking
Throat loszenges
Saline nose drops
Decongestants

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32
Q

Influenza: Complications

A

Acute bronchitis
Influenza related pneumonia
Exacerbations of asthma, COPD, HF

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33
Q

Influenza: Vaccinations

A

Influenza vaccine is an inactivated vaccine tailored each year according to recent outbreaks.

Free flu vaccine eligability-
» pregnant
» front-line healthcare worker
» long-term care home residant
» carer
» patients with chronic conditions
» age over 65
» very overweight

Children-
» 6-12 months should have flu jab
» 2-17 years have yearly nasal spray vaccine

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34
Q

Pneumonia: Definition

A

Lung tissue infection that causes the air sacs in the lungs to fill with fluid, inflammatory cells, and microorganism.
» leads to consolidation of the lung tissue
» impairs gas exchange and can lead to hypoxia

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35
Q

Pneumonia: Types

A

Types of pneumonia:

> > Community-acquired pneumonia (CAP)

> > Hospital-acquired pneumonia (HAP)

> > Pneumonia in immunocompromised individuals

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36
Q

Pneumonia: Aetiology

A

Pneumonia can be caused by viruses, bacteria, and fungi

> > most common: Strep pneumonia
common: Staph aureus, Mycoplasma pneumoniae, Haemophilus influenzae
uncommon: klebsiella pneumonia, strep pyogenes, pseudomonas, aeruginosa, Coxiella burnetti, Chlamydia psittaci, Actinomyces Israeli

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37
Q

Pneumonia: Pathophysiology

A

> > Inflammation of lungs due to infection
fluid and blood cell leak
consolidated tissue
impaired gas exchange
reduced ventilation

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38
Q

Pneumonia: Risk Factors

A

Age&raquo_space; infants and the elderly
Smoking
Alcohol excess&raquo_space; organ damage, aspiration pneumonia
Preceding viral infections&raquo_space; flu
Bronchial obstruction&raquo_space; COPD
Bronchiectasis&raquo_space; permanent widening and thickening of lung airways
Immunosuppression&raquo_space; AIDS, chemotherapy
Hospitalisation
Underlying predisposing disease&raquo_space; Diabetes, CVD

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39
Q

Pneumonia: Symptoms

A

Fever
Sweating
Shivers
Malaise
Rigors
Cough
Purulent sputum
Pleuritic chest pain&raquo_space; chest pain on inspiration
Haemoptysis

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40
Q

Pneumonia: Signs

A

Tachypnoea
Tachycardia
Hypotension
Cyanosis
Dullness to percussion over the consolidated area
Increased vocal resonance/ tactile vocal fremitus over the consolidated area
Pleural rub
Lower lobe crackles

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41
Q

Pneumonia: Investigations

A

Sputum culture
CXR&raquo_space; consolidation and fluid
FBC
U+E&raquo_space; for AKI
LFTs

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42
Q

Pneumonia: Management

A

Oxygen if low saturations
IV fluids if dehydrated
Analgesia for myalgia or chest pain
Escalate for respiratory support

Oral antibiotics&raquo_space; amoxicillin 500mg, 3x per day for 5 days
IV antibiotics for those admitted with more severe pneumonia&raquo_space; co-amoxiclav and clarithromycin
» check for penicillin allergies
Antibiotics should be tailored to antimicrobial sensitivities

Repeat CHX after 6-8 weeks&raquo_space; screen for lung cancer

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43
Q

Streptococcus Pneumonia: Definition

A

Infection of lungs caused by streptococcus pneumoniae bacteria
Homogeneous consolidation of one or more lobes or segments

> > also called pneumococcal pneumonia, community acquired pneumonia

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44
Q

Streptococcus Pneumonia: Epidemiology

A

All ages&raquo_space; specifically early and middle adult life

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45
Q

Streptococcus Pneumonia: Pathophysiology

A

Droplet spread
Streptoccocus pneumoniae

> > inflammation of lungs due to infection
fluid and blood cell leak
consolidated tissue
impaired gas exchange
reduced ventilation

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46
Q

Streptococcus Pneumonia: Symptoms

A

Cough
Purulent sputum
Fever
Aches and pains
Vomiting
Anorexia
Pleuritic chest pain
Dyspnoea

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47
Q

Streptococcus Pneumonia: Investigations

A

FOR ALL PATIENTS WITH PNEUMONIA-
Chest X-ray
Sputum culture&raquo_space; only in secondary care and if urgent
FBC&raquo_space; WBC
U&E&raquo_space; urea
LFTs&raquo_space; albumin

48
Q

Streptococcus Pneumonia: Management

A

Penicillin or cephalosporin

49
Q

Streptococcus Pneumonia: CURB-65 Score

A

Classified using the CURB-65 score to determine severity and guide management

One point is awarded for each of the following-
» confusion
» urea > 7mmol/L
» respiratory rate > 30 breaths/min
» blood pressure < 90 systolic and/or < 60mmHg diastolic
» 65 years or older

A CURB-65 score of:
» 0-1 requires home treatment
» 2 should consider hospital admission
» 3-5 admit to hospital and consider ITU referral

50
Q

Streptococcus Pneumonia: Complications

A

Exudate
Pleural effusion
Lung abscess

Bacteraemia&raquo_space; sepsis, endocarditis, meningitis, arthiritis, otitis media

51
Q

Atypical Pneumonia: Definition

A

Less common
Not detectable on gram staining

52
Q

Atypical Pneumonia: Epidemiology

A

Commonly affect healthier people
Typically less severe&raquo_space; more severe in immuno-compromised

53
Q

Atypical Pneumonia: Pathophysiology

A

Organisms that cause atypical pneumonia-

Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumophila

54
Q

Atypical Pneumonia: Mycoplasma pneumonia

A

Caused by: Mycoplasma pneumoniae
Most common cause of atypical pneumonia

Epidemiology-
Peak rate in autumn/early winter
Epidemic every 3-4 years

Risk Factors-
Common in barracks and institutions
Children and young adults at higher risk

Symptoms-
Present insidiously with flu-like symptoms
» progresses to pnuemonia symptoms
» PERSISTANT DRY COUGH

Investigations-
CXR or CT consolidation
» homogenous dense lobar, patchy, nodular

Treatment-
erythromycin/clarithromycin or tetracycline

55
Q

Atypical Pneumonia: Legionella pneumonia

A

Caused by: Legionella pneumophila
Mortality 15%&raquo_space; most commonly due to resp. failure

Epidemiology-
Typically present in water sources
» can spread via air conditioning

Symptoms-
Previously healthy paitent&raquo_space; air conditions
Present with: cough, chills, temp, myalgia, nausea, vomitting, diarrhoea, confusion
PLEURITIC CHEST PAIN AND COUGH

Investigations-
CXR, blood culture, Legionella serology, urine antigen

Treatment-
Erythromycin 14-21 days, oxygen, IV fluids&raquo_space; 1st line
Rifampicin BD by mouth or IV&raquo_space; severly ill patients

Complications-
Less severe: confusion, hepatitis, renal impairement
More severe: hyponatreamia, lung abscess, empyema, hypotension

56
Q

Atypical Pneumonia: Chlamydophila pneumonia

A

Caused by: Chlamydophila pneumoniae
Mortality 15%&raquo_space; most commonly due to resp. failure

Epidemiology-
Most common chlamydial infection
Spread via droplets
Biphasic illness

Symptoms-
Present with: pharyngitis, hoarsness, otitis media&raquo_space; followed by pneumonia
PRODUCTIVE WATERY COUGH

Investigations-
CXR, chlamydial PCR, nasopharyngeal swab, sputum or pleural fluid sample

Treatment-
Azithromycin&raquo_space; 1st line
Tetracyclin&raquo_space; 2nd line

57
Q

Atypical Pneumonia: Investigations

A

CXR, blood cultures, serology, chlamydial PCR

Mycoplasma pneumoniae- ground-glass shadowing
Chlamydophila pneumoniae- consolidation
Legionella pneumophila- patchy consolidation

58
Q

Atypical Pneumonia: Management

A

Responds to antibiotics: macrolides (azithromycin and clarithromycin) and doxycycline

59
Q

Hospital Acquired Pneumonia: Definition

A

Pneumonia acquired less than 48 hours after admission to hospital

60
Q

Hospital Acquired Pneumonia: Epidemiology

A

More likely than pneumonia acquired at home

61
Q

Hospital Acquired Pneumonia: Pathophysiology

A

Most common causative organisms-

Pseudomonas aeruginoa
Staphylococcal aureus
Enterobacteriaceae&raquo_space; Klebsiella, E.coli, Enterobacter

62
Q

Hospital Acquired Pneumonia: Staph. Aureus

A

Epidemiology:
2% of pneumonia in UK
Typically secondary to influenza infection

Pathophysiology:
Widespread infection with abscess formation
Seen in immunocompromised patients

Risk Factors:
Intravenous drug abusers&raquo_space; puncture sites introduce infections

Treatment:
Flucloxacillin&raquo_space; 1st line
Erythromycin&raquo_space; if allergic

63
Q

Hospital Acquired Pneumonia: Klebsiella Pneumonia

A

Epidemiology:
Uncommon
High mortality 20-50%

Pathophysiology:
Massive consolidation and excavation of lobes
» ususally upper lobes

Presentation:
High fever, rigors, pleuritic pain
Sputum is purulent, haemoptysis

Risk Factors:
Associated with alcoholism, diabetes, COPD, elderly

Treatment:
Cefuroxime

64
Q

Hospital Acquired Pneumonia: Pseudomonas Pneumonia

A

Risk Factors:
Common pathogen in bronchiectasis, CF, hospital acquired infections (ITU, post-surgery)

Diagnosis:
Sputum culture

Treatment:
Antipseudonomal penicillin

65
Q

Pneumocystic Jirovecii Pneumonia: Definition

A

Pneumocystis carinii pneumonia (PCP)
Pneumocystic jirovecii pneumonia (PJP)

Pnemonia in the immunosupressed

66
Q

Pneumocystic Jirovecii Pneumonia: Pathophysiology

A

Caused by fungus: pneumocystis jirovecii

67
Q

Pneumocystic Jirovecii Pneumonia: Symptoms

A

Dry cough
Exertional dyspnoea
Hypoxaemia
Fever
Bilateral crepitations

68
Q

Pneumocystic Jirovecii Pneumonia: Investigations

A

CXR&raquo_space; normal OR bilateral peripheral interstitial shadowing
Visulisation of organisam in sputum
Bronchoalveolar lavage (BAL)&raquo_space; tube with fluid put down and brough back up

69
Q

Pneumocystic Jirovecii Pneumonia: Treatment

A

High dose co-trimoxazole, pentamidine
Steroid if hypoxaemia

Prophylaxis if CD4 count <200
(normal CD4 500-1200)

70
Q

Acute Bronchiolitis: Definition

A

LRTI of bronchioles causing inflamamtion in small bronchi and bronchioles

71
Q

Acute Bronchiolitis: Epidemiology

A

Typically seen in infants and young children <2 years
During autumn and winter

72
Q

Acute Bronchiolitis: Pathophysiology

A

Viruses infect bronchiolar epithelial cells&raquo_space; inflammation in small bronchi and bronchioles

Common caused by respiratory syncytial virus (RSV)&raquo_space; commonly causes bronchiolitis in infant and pneumonia in adults
» other causes: rhinovirus, parainfluenza, influenza, COVID, adenovirus

73
Q

Acute Bronchiolitis: Symptoms and Signs

A

Fever
Nasal congestion
Rhinorrhoea

Persistant cough
Dyspnoea&raquo_space; difficulty breathing
Wheeze
Intercostal rescession
Peripheral cynosis

Typically begins with URTI, progresses to LRTI

74
Q

Acute Bronchiolitis: Diagnosis

A

Clinical diagnosis
Respiratory exam

CXR or virology&raquo_space; only if other concerns

75
Q

Acute Bronchiolitis: Management

A

Self-limiting&raquo_space; typically resolves within 1-2 weeks

Supportive care-
» analgesia, hydration, nutrition

Indications for hospitalisation-
» toxic appearacnce, central cyanosis, lethargy, dehydration, severe resp. distress, hypoxia

A&E management-
» Inhaled bronchodilators, IV fluids, oxygen, nasal suction, intubation

76
Q

Croup: Definiton

A

URTI also known as acute laryngotracheobronchitis

77
Q

Croup: Epidemiology

A

Affects children between 6 months - 6 years
» peak incidence at 2 years

More often in autumn and winter

78
Q

Croup: Pathophysiology

A

Most common cause: human parainfluenza virus 1

Infection and inflammation of laryngeal mucosa
» laryngeal oedeam, thick tenacious mucus
» obstructed trachea and airways

Onset slower than acute epiglottitis

79
Q

Croup: Symptoms and Signs

A

Prodromal phase of coryzal symptoms

Harsh barking cough
Hoarse voice or cry
Inspiratory stridor

80
Q

Croup: Modified Westley Score

A

Modified Westley scoring:
» chest wall retractions
» stridor
» cyanosis
» level of consiousness
» air entry

0–2: Mild croup
3–5: Moderate croup
6–11: Severe croup
12–17: Impending respiratory failure

81
Q

Croup: Investigations

A

Clinical diagnosis
Use modified Westley score for severity

82
Q

Croup: Treatment

A

Largely self-limiting

Supportive care-
» analgesia, hydration, nutrition, rested, oxygen, fever management

Severe care-
» dexamethasone 150mcg orally (steroid)
» nebulised budesonide 2mg (steroid)
» nebulsied adrenaline 5mg

83
Q

Pertussis: Definition

A

Highly contagious bacterial infection of the lungs and airways

84
Q

Pertussis: Epidemiology

A

Under 6 months&raquo_space; increased mortality

85
Q

Pertussis: Pathophysiology

A

Bordetella pertussis - gram negative bacteria

86
Q

Pertussis: Symptoms and Signs

A

Cough paroxysm&raquo_space; coughing fit
Long-term hacking cough
Whooping cough
Post-cough vomitting

87
Q

Pertussis: Investigations

A

Nasopharyngeal swab
» idealy under 2 weeks

Oral fluid swabs
Serology-anti-pertussis toxin IgG
» over 2 weeks

88
Q

Pertussis: Management

A

Vaccine-
» for 16-31 weeks pregnant
» childhood scheduled vaccines

Hospital admission if under 6 months, or severly unwell
Macrolides to reduce infective peroid&raquo_space; clarithromycin, azithromycin
Oxygen if cyanosis

89
Q

Acute Epiglotittis: Definition

A

Inflammation and swelling of the epiglottis

MEDICAL EMERGENCY

90
Q

Acute Epiglotittis: Epidemiology

A

Rare

Children 2-5 years
Adults 40-50 years

91
Q

Acute Epiglotittis: Pathophysiology

A

Commonly caused by: haemophilus influenzae, streptoccocus pneumoniae

Localised infection of supraglottic larynx

92
Q

Acute Epiglotittis: Symptoms and Signs

A

Muffled voice (hot potatoe voice)
Hoarse cry
Stridor
Drooling
Fever
Painful/inability to swallow
Tripod position
Fever
No cough

93
Q

Acute Epiglotittis: Investigation

A

DO NOT LOOK INSIDE MOUTH&raquo_space; may exacerbate

94
Q

Acute Epiglotittis: Management

A

Emergency referal

Airway management
Manage fever
Refer laryngoscopy&raquo_space; gold standard
IV antibiotics

95
Q

Tuberculosis: Definition

A

Tuberculosis is an infection with the Mycobacterium tuberculosis bacterium
Lung is the major seat of infection and the usual portal through which infection reaches other organs
» can infect multiple other organ systems

Active TB: symptomatic, progressive, and contagious
Latent TB: persistent immune response to prior acquired antigens, forms tuberculoma&raquo_space; asymptomatic and not contagious

96
Q

Tuberculosis: Epidemiology

A

High incidence in Africa and Asia
Multi drug resistant TB is a public health crisis&raquo_space; notifiable disease in UK

2nd leading infectious killer
TB is present in all countries and age groups but is curable and preventable

97
Q

Tuberculosis: Pathophysiology

A

Mycobacterium tuberculosis: aerobic, slow growing bacteria
» acid fast bacilli: resistant to acid staining

Spread via droplets
» Bacteria enters respiratory system
» 70% people will clear infection

Others may become infected and supress the disease and so show no signs or symptoms&raquo_space; latent TB
» latent TB: granulomas will form around the bacteria to prevent immune system from attacking it
» TB bacteria remains in body, inactive

Others develop disease immedietly&raquo_space; active TB

98
Q

Tuberculosis: Types

A

Active TB: patient is symptomatic or there is progression of the disease in the lung or other organs&raquo_space; most common presentation

Miliary TB: a severe and disseminated form of TB, where the bacteria spread through the bloodstream, affecting multiple organs throughout the body

Latent TB: the immune system contains the infection, with alveolar macrophages playing a major role in the formation of granulomas which contain the bacteria
» asymptomatic and not contagious

Reactive TB: if latent TB becomes reactive&raquo_space; 5-10% of people with latent TB will experience

99
Q

Tuberculosis: Risk Factors

A

Close contact of TB patient
Homeless patients or living in close quarters
Alcohol and other drug misuse
Immunocompromised patients&raquo_space; HIV
Elderly patients

100
Q

Tuberculosis: Common Symptoms and Signs

A

Systemic-
Night sweats
Fevers
Weight loss
Malaise
Lymphadenopathy

Respiratory-
Chronic productive cough
Haemoptysis
Shortness of breath
Collapse, pain, or pleural effusion&raquo_space; dull to precussion

101
Q

Tuberculosis: Other Symptoms and Signs

A

Heart and pericardium: pain, arrhythmias, cardiac failure, pericarditis
Intestine: malabsorption, diarrhoea, obstruction
GI tract: haematuria, renal failure, epididymitis, salpingitis, infertility
Skin: erythema nodosum, lupus vulgaris
Eyes: iritis, choroiditis, keratoconjunctivitis
Bones/Joints: arthritis, osteomyelitis
Lymphatics: lymphadenopathy, cold abscesses, sinuses
Brain: tuberculoma, meningitis

102
Q

Tuberculosis: Active TB Investigations

A

If active TB suspected-
Chest X-ray

Sputum culture x3
» for acid fast bacilli smear, mycobacterial culture, nucleic acid amplification testing (NAAT)
» samples for microscopy, culture and sensitivity testing (MCS)
» stained with Ziehl-Neelsen or Auramine staining
» at least one sample from early morning

Additional testing depending on suspected site of infection

103
Q

Tuberculosis: Latent TB Investigations

A

If inactive TB is suspected-
Mantoux test
» injecting 0.1mL of liquid containing tuberculin purified protein derivative(PPD) into top layers of forearm skin
» check 48-72 hours after injection
» positive if ≥5 mm skin induration

Interferon-gamma release assay test
» a blood test which detects the white blood cell response to TB antigens
» faster, less false positives

If Mantoux or IGRA tests positive, should exclude active TB
» history
» physical examination
» chest x-ray: granulmoas/nodules
» Any other abnormalities: send for sputum test

104
Q

Tuberculosis: Ative TB Treatment

A

Initial 2 months of-
» rifampicin (colours urine, sweat, and tears red/brown 4 hours after dose)(not allowed contraception for 8 weeks after Rifampicin)
» isoniazid with pyradoxine (vit B6 to mitigate common neuro side effects)
» pyrazinamide
» ethambutol

Followed by 4 month of-
» rifampicin
» isoniazid with pyradoxine (vit B6)

TREATMENT STARTED IF SUSPECTED OF ACTIVE TB without waiting for culture results, then modified
Compliance is CRUCIAL&raquo_space; risk of multi-drug resistant TB
Modify treatment regimen according to drug susceptability testing
Longer courses of antibiotics in TB meningitis, pericardial and spinal TB&raquo_space; affecting CNS
Multidrug-resistant TB often requires 18-24 months of treatment with at least six drugs

Contact tracing, care co-ordination via TB MDT, monitor adherence, mask until >2 weeks of treatment

105
Q

Tuberculosis: Latent TB Treatment

A

For 3 months-
» rifampicin
» isoniazid with pyradoxine (vit B6)

OR

For 6 months-
» isoniazid with pyradoxine (vit B6)

106
Q

Tuberculosis: Prevention

A

BCG vaccination is a live attenuated vaccine that is given to protect against TB
It is not a routine part of the UK’s childhood vaccination schedule but is given to babies (or children up to 16) at higher risk

107
Q

Tuberculosis: Complications

A

Pleural effusion
Empyema&raquo_space; collection of pus in pleural cavity
Pneumothorax&raquo_space; collapsed lung, air leaking from lung within pleural cavity
Laryngitis
Enteritis&raquo_space; inflammation of small intestine
Mycetoma
Cor pulmonale
Death

108
Q

Pleural Effusion: Definition

A

Accumulation of excess fluid within pleural cavity
» impede respiration as the lung cannot expand fully

X-ray&raquo_space; white=fluid

109
Q

Pleural Effusion: Pathophysiology

A

Causes classified into trasudative or exudative-

Transudative: where changes in oncotic and hydrostatic pressure cause fluid to leak from the vasculature
&raquo_space; typically watery, transparent
» causes: HF, renal failure, liver failure, PE
» lower pleural proteins

Exudative: where inflammation leads to increased microvascular permeability and drainage of pleural fluid may be impaired
» contains materials, pus
» causes: infection, cancer, autoimmune, drugs, PE
» can have right-sided or left-sided secondary causes
» higher pleural proteins

110
Q

Pleural Effusion: Light’s criteria

A

Used to differentiate between transudative and exudative plural effusion

If any criteria met, then exudative:
» ratio of pleural to serum protein is greater than 0.5
» ratio of pleural to serum LDH is greater than 0.6
» pleural fluid LDH is greater than ⅔ of the upper limit of normal serum value

111
Q

Pleural Effusion: Symptoms

A

Shortness of breath
Reduced exercise tolerance
Dry cough
Pleuritic chest pain&raquo_space; sharp, stabbing, worsens on breathing in and out, holding breath helps

112
Q

Pleural Effusion: Signs

A

Reduced chest expansion on the affected side
Dull on percussion over the effusion
Reduced or absent breath sounds over the effusion
Loss of vocal resonance over the effusion
Tracheal deviation away from the effusion
Respiratory distress&raquo_space; use of accessory muscles

HF: peripheral oedema, raised JVP

113
Q

Pleural Effusion: Differential Diagnosis

A

Haemothorax:
» a collection of blood in pleural cavity
» usually secondary to trauma
» can occur spontaneously&raquo_space; due to malignancy or vascular rupture

Chylothorax:
» chylous fluid in the pleural cavity
» due to lymphatic duct injury or obstruction
» common causes include iatrogenic injury during thoracic surgery, traumatic injury or lymphoma

Empyema:
» a collection of pus in the pleural cavity
» usually develop as a complication of pneumonia

Mesothelioma:
» tumour of the pleura
» strongly associated with asbestos exposure.

114
Q

Pleural Effusion: Investigations

A

Respiratory exam:
» pleural tap, vocal resosonance, chest sounds

Chest X-ray:
first line&raquo_space; blunting of costophrenic angle or white out of the lung

FBC

115
Q

Pleural Effusion: Management

A

Thoracocentesis:
» pleural tap or pleural aspiration
» is a minimally invasive medical procedure that removes fluid or air from the pleural space

> > sit patient upright
leaning on pillow
insert needle and drain fluid out above rib to avoid neurovascular bundle for diagnosis and symptom relief

Management and treatment depends on size, symptom and cause

Respiratory Disease (1 decks)

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