Respiratory Diseases Flashcards
what is FEV1
Forced Expiratory Volume of air exiting the lung in the first second after taking a deep breath and blowing out
is usually about 70-80% of FVC
usually 3.5-4litres
what is FVC
Final Total amount or air expired
around 5 litres
(forced vital capacity)
what is the normal ratio FEV1 : FVC
Normal ratio FEV1 : FVC is 0.7 – 0.8
how do you carry find out FEV1 and FVC
spirometry
how else can obstructive lung diseases be demonstrated
Peak Expiratory Flow Rate (PEFR)
Normal 400 – 600 litres/min
what are the key features in Obstructive Lung Disease
There is AIRFLOW LIMITATION Peak Expiratory Flow Rate (PEFR) is reduced FEV1 is REDUCED FVC may be reduced FEV1 is less than 70% of FVC
what are the most common obstructive airway diseases
CHRONIC BRONCHITIS
EMPHYSEMA
ASTHMA
COPD - chronic obstructive pulmonary disease
what is the aetiology of COPD
smoking
atmospheric - pollution
occuaption - dust
age
what is Chronic Bronchitis defined CLINICALLY as
Cough productive of sputum most days
in at least 3 consecutive months for 2 or more consecutive years
Complicated chronic bronchitis when sputum turns mucopurulent (acute infective exacerbation) or FEV1 falls
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what are morphological changes in chronic bronchitis in large airways
Mucous gland hyperplasia
Goblet cell hyperplasia (increase)
Inflammation and fibrosis is a minor component
what are morphological changes in chronic bronchitis in small airways
Goblet cells appear (produce muscous)
Inflammation and fibrosis in long standing disease
what is emphysema
Increase beyond the normal in the size of airspaces distal to the terminal bronchiole arising either from dilatation or from destruction of their walls and without obvious fibrosis.
alveoli are damaged. inner walls of the air sacs weaken and rupture — creating larger air spaces instead of many small ones
what is the acinus
everything distal from the terminal bronchi (respiratory zone)
what is centriacinar emphysema
in upper part of lungs
alveoli are damaged, increased spaces in lungs
just after terminal bronchi
what is pan-acinar emphysema
large areas of lung lost in lower parts of lung
what is peri-acinar emphysema
tissue lost around edges of acinus, next to pleura usually
whats a bulla
is an emphysematous space greater than 1cm
what does the term ‘bleb’ mean
air containing spaces just underneath
the pleura
what is the protease-antiprotease imbalance and what induces it
smoking induces
elastase (protease) from neutrophils + macrophages
anti-elastase, protect elastin framework in alveolar tissue as prevent build of elastase
if alpha 1 trypsin deficiency, no anti-elastase, build of elastase = tissue destruction = emphysema
In EMPHYSEMA LOSS OF ALVEOLAR ATTACHMENTS, mechanism of airway obstruction, cant hold alveoli open
hhh bb
what force holds alveoli open
radial force
why do you get hypoxaemia in COPD
- airway obstruction
- reduced respiratory drive
- loss of alveolar surface area
- shunt
what pulmonary vascular changes occur in hypoxia
pulmonary arteriolar vasoconstriction
protective mechanism
Dont send blood to alveoli short of oxygen!
what can happen to the heart if there is chronic hypoxia in the lungs
Hypertrophy of the Right Ventricle
Cor Pulomale - right sided heart failure
due to inc pressure in right ventricle
what are distinct features of asthma
wheeze
variability
respond to treatment
No wheeze = No asthma!
its reversible
what is asthma
chronic
wheeze, cough, SOB
difficulty on expiration
increased reactivity of the trachea and bronchi to various stimuli - inc airway reactivity
narrowing of airways (smooth muscles constrict)
inflammation
airflow obstruction
what causes asthma
Genes
ADAM33, ORMDL3
Interact with environment
Epigenetics
how can an allergy cause asthma
epithelial abnormality
allergen gets through
fuels eczema/asthma
how can you diagnose asthma in children
all in history taking
examination unhelpful
no diagnostic test for children
what are the NICE guidelines for diagnosing asthma in children
Spirometry
BDR (broncho dilator response)
FeNO (nitric oxide)
Peak flow
at what age is uncertainty greatest for asthma diagnosis
under 5 year olds
asthma - SoB at rest
<30% lung function
- dry cough
fdfd
what asthma treatment would you give to children
ICS for 2 months (inhaled corticosteroids) brown inhalor
if QoL affected
in under 18months it is mostly infection not asthma but could be if it points to it
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what are the goals of asthma treatment
“minimal” symptoms during day and night
minimal need for reliever medication
no attacks (exacerbations)
no limitation of physical activity
what questions can you ask to work out the lung function of children for asthma
SANE Short acting beta agonist/week (blue inhaler) Absence school/nursery Nocturnal symptoms/week Excertional symptoms/week
what are the classes of medication for asthma
Short acting beta agonist (blue) Inhaled corticosteroids (ICS) (brown)
add ons:
long acting beta agonists (LABA)
leukotriene receptor antagonist (LTRA)
what is the max dose of ICS in under 12 year olds
800 microg
what is an adverse effect of Inhaled corticosteroids
Height suppression 0.5-1cm
oral thrush
what do you have to use long acting beta agonist with
must use with ICS
what add ons do you use to ICS in children
long acting beta agonists (LABA)
leukotriene receptor antagonist (LTRA)
inc ICS dose
in under 5s what is the first line preventer for asthma
leukotriene receptor antagonist (LTRA)
what are the 2 types of delivery systems for asthma
MDI/spacer - shake and wash (reduce static)
around 20% lung deposition w spacer
Dry powder device 20% deposition (for 8-11yr olds) girls
nebulisers for asthma not that great
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what other management can be done to reduce asthma
Stop tobacco smoke exposure
Remove environmental triggers
Cat, Dog
what does asthma treatment depend on
Respiratory rate
Work of breathing
Oxygen saturations
for acute asthma what treatment would you use, for light symptoms
SABA via spacer, is a bronchodilator
oral prednisolone
for acute asthma what treatment would you use, for moderate symptoms
SABA via nebuliser + oral prednisolone
whats an effect of SABA
can give palpitations
for acute asthma what treatment would you use, for severe symptoms
IV salbutamol IV magnesium (nebuliser)
what is the pathophysiology of asthma
increased airway reactivity
narrowing of airways
walls become thickened and inflamed
what are the risk factors for asthma
-hereditary
atopy - predisposition to develop immunoglobulin E (IgE) in response to allergens
- smoking
- occupation
- obesity
- diet
- reduced exposure to microbes
in adults how would you diagnose asthma
present w symptoms
look at history
clinical examination
what are the symptoms of asthma
Wheeze
Shortness of breath (dyspnoea)
Chest tightness
Cough, paroxysmal, usually dry
are variable symptoms
what do you look for in clinical examination in asthma
Breathless on exertion
Hyperinflated chest
Wheeze
what could it be instead of asthma that has wheeze, cough, chest tightness
COPD
bronchiectasis
cystic fibrosis
tumour
what investigations would you do for asthma
Spirometry
Peak Flow tests
Full pulmonary function testing, excludes COPD/emphysema
Check response to bronchodilator, reversibility
Response to oral corticosteroids , reversibility
chest x-ray
skin prick testing
total and specific IgE
full blood count
what objective assessment can you do to assess acute asthma
Ability to speak Heart rate Respiratory rate PEF Oxygen saturation / Arterial blood gases
what are the features of moderate asthma
Able to speak, complete sentences
HR < 110
RR < 25
PEF 50 - 75% predicted or best
what are the features of severe asthma
Inability to complete sentences in one breath
HR ≥110
RR ≥25
PEF 33 - 50% predicted or best
what are the features of life threatening asthma
Grunting Impaired consciousness, confusion, exhaustion Bradycardia/ arrhythmia/ hypotension PEF < 33% predicted or best Cyanosis Silent chest Poor respiratory effort
PaO2 < 8kPa (60mmhg)
what are the features of fatal asthma
Raised PaCO2
Need for mechanical ventilation
what are the features of complete control of asthma
no daytime symptoms no night time wakening no need for rescue medication no asthma attacks no limitations on activity including exercise normal lung function minimal side effects from medication.
what is some non pharmacological management of asthma
Patient Education and Self management plans Exercise Smoking cessation Weight management Flu vaccinations
what are the benefits of inhalers
Small dose of drugs
Delivery directly to the target organ (airways and lung)
Onset of effect is faster
Minimal systemic exposure
what are some reliever drugs for asthma in adults, symptom control
Short acting β2 agonists (SABA)
e.g. salbutamol
whats pharmacological treatment is there for asthma in adults
Inhaled therapy
Oral therapy
Specialist treatments
what inhaled therapy would you start with for asthma
inhaled coritcosteroids
increase dose
long acting beta agonists
what oral therapy is there for asthma
Leukotriene Receptor Antagonist
Theophylline
Prednisolone
what specialist treatment is there for asthma
Omalizumab (Anti- IgE)
Mepolizumab (Anti-Interleukin-5)
Bronchial thermoplasty
what would you do for someone having a mild/moderate asthma attack
increase inhaler use
oral steroid
treat trigger
what would you do for moderate/severe asthma in the hospital
Nebulisers - Salbutamol/Ipratropium
Oral/IV Steroid
Aminophylline
what are the two types of inhaler
dry powder inhalers
metered dose inhalers w spacer
what is COPD
chronic obstruction of lung airflow that interferes with normal breathing
is not fully reversible.
what is the pathophysiology of COPD
chronic inflammation causes structural changes
-narrowing of small airways
- destruction of lung parenchyma
- loss of alveolar attachment, decrease lung elastic recoil
decrease ability of airways to remain open during expiration
what is the main cause of COPD
smoking
pollutants
inc age
what is alpha-1 antitrypsin defiiceny
inherited disease
protease inhibitor made in the liver, limits damage caused by activated neutrophils releasing elastase in response to infection/cigarette smoke
When absent/low -> alveolar damage and emphysema
what are symptoms of COPD
Cough Breathlessness Sputum Frequent chest infections Wheezing
what may you find on clinical examination for COPD
cyanosis raised JVP wheeze hyperinflated chest use of accessory muscles to breath peripheral oedema
what test can you do to see if its COPD
spirometry
what criteria’s must you meet to diagnose COPD
Typical symptoms
>35 years
Presence of risk factor (smoking or occupational exposure)
Absence of clinical features of asthma
Airflow obstruction confirmed by post-bronchodilator spirometry
what would the FEV1/FVC be for COPD
FEV1/FVC <0.7 post bronchodilator
what would FEV1 be in mild copd
FEV1 80% of predicted value or higher
what would FEV1 be in moderate copd
FEV1 50–79% of predicted value
what would FEV1 be in severe copd
FEV1 30–49% of predicted value.
what would FEV1 be in very severe copd
FEV1 less than 30% of predicted valu
what investigation can you do to exclude other pathologies in copd
Chest X-ray
how can you ensure its COPD and not a differential diagnosis
pulmonary function tests, inc residual volume
radiology, CT
what is an exacerbation
Worsening of symptoms
what are exacerbations of COPD
SOB Wheeze Chest tightness Cough Sputum – purulence / volume
what are severe exacerbations of COPD
Breathless (RR>25/min) Accessory muscle use at rest Purse lip breathing Fluid retention Cyanosis (Sats <92% o/a) confusion
what investigations would you do for acute exacerbation of COPD in 2ndry care
CXR, blood gases, FBC, U&E, sputum culture, VT
what is type 1 respiratory failure
dec pO2
what is type 2 respiratory failure
dec pO2 and inc pCO2 (reduced sensitivity to pCO2 - hypoxic drive)
in emphysema what happens to V/Q relationship
reduced V/Q matched
what is cor pulmonale, what does it look like on ecg
right sided heart failure due to lungs
T wave inversion V1-V4
what is secondary polycythaemia
Body produces ↑ erythropoietin in response to low O2
↑ Haemoglobin, ↑ Haematocrit
↑ bloody viscosity
what is the overall effect of alveolar hypoxia
compensatory vasoconstriction, shunt blood flow to healthy alveoli
Back pressure leading to Pulmonary arterial hypertension + RH failure
RV enlarges, reduces the LV function,
reduced circulating volume – activates kidneys Renin-aldosterone-angiotensin system – fluid retention
what are some Non- Pharmacological
Managements for COPD
Smoking Cessation • Vaccinations – Flu and Pneumococcal vaccine • Pulmonary Rehabilitation • Nutritional assessment • Psychological support
what are inhaled therapies for COPD
Short acting Bronchodilators
– SABA (eg- Salbutamol)
– SAMA (eg- Ipratropium)
Long acting bronchodilator
- LAMA (Long acting anti – muscarinic agents)
– LABA (Long acting B
2 agonist, eg- Salmeterol)
high dose inhaled corticosteroids (ICS) and LABA
what would you give to a patient with COPD with exacerbations
SABA and LAMA
when would you give someoone with COPD long term oxygen
when PaO2 <7.3kPa
what primary care management would you do for COPD
SABA
steroids - prednisolone
antibiotics
hospital admission if unwell
what investigations would you do for someone amditted into hospital for COPD
FBC biochemistry + glucose arterial blood gas electrocardiograph CXR blood cultures sputum microscopy
in the ward how would you treat a patient w COPD
Oxygen- target Saturation 88-92% • Nebulised bronchodilators • Corticosteroids • Antibiotics (Oral Vs IV)
what are some palliative car e methods for COPD patients
- Management of Breathlessness and Dysfunctional
breathing - Anticipatory Care Plan
what is acute epiglottis, what causes it
URTI
Haemophilus influenzae
Group A beta-haemolytic Streptococci
what are some respiratory Tract Defence Mechanisms
Macrophage-mucociliary escalator system
General immune system
Respiratory tract secretions
Upper respiratory tract as a ‘filter’
what is the macrophage-mucociliary escalator syste
alveolar macrophages, towards ciliated airways
mucociliary escalator
cough reflex
keeps lower resp tract sterile
what aetiological classification of Pneumonia are there
Community Acquired Pneumonia
Hospital Acquired (Nosocomial) Pneumonia
Pneumonia in the Immunocompromised
etc
what are the patterns of pneumonia
Bronchopneumonia
Segmental, part of lobe
Lobar
whats bronchopneumonia
multifocal, both lungs
infect in small airways -> alveoli -> pus from inflammation -> fill airspaces
what are the outcomes of pneumonia
resolve
pleural Effusion and Empyema
lung abscess
bronchiectasis
what circumstances may cause a lung abscess
obstructed bronchus - tumour
food aspiration
partic organism - staph aureus, pneumococci
what is bronchiectasis
Pathological dilatation of bronchi due to
- Severe Infective Episode
- Recurrent Infections
- Proximal Bronchial Obstruction
dilate to inappropriate size, fill up w mucus and become infected
what are the symptoms of bronchiectasis
COUGH, ABUNDANT PURULENT FOUL SPUTUM, haemoptysis, signs of chronic infection
Coarse crackles, clubbing
how may you get aspiration pneumonia
Vomiting
Oesophageal Lesion
sedation
what are opportunist infections
Infection by organisms not normally capable of producing disease in patients with intact lung defences - opportunistic pathogens
where can you get URTI
note, mouth, pharynx, larynx, epiglottis
what is otitis media
infection in ear, red
ear ache, self limiting
primary viral infection
2ndry pneumococcus
how do you treat tonsilitis
Either nothing or 10 days penicillin
Don’t give amoxycillin
what can you use to treat otitis media
analgesia (relieve pain)
antibiotics may work
what are self-limiting infections
can resolve without any treatment
what causes croup and what are the symptoms
Para’flu I
stridor, hoarse voice, “barking” cough
what cause epiglottitis
H. influenzae Type B
Stridor, drooling
what can treat croup
Oral dexamethasone
what can treat epiglottitis
Intubation and antibiotics
what are common infective agents
bacterial - Strep pneumoniae, Haemophilus influenzae, Moraxella catarrhalis,
viral - RSV, parainfluenza III, influenza
how do you assess patient with LTRI
check oxygenation, hydration, nutrition
what is tracheitis and what can u use to treat
swollen tracheal wall, narrowed lumen and lumen debris
staph or strep invasive infection
augmentin - antibiotic
what is bronchitis
Endobronchial infection
Loose rattly cough with URTIChest free of wheeze/creps
Haemophilus/Pneumococcus
Mostly self-limiting
may have disturbed mucociliary clearance - so secretions pool in airways
whats bronchiolitis
LRTI of infants in <12 months one off, not recurrent RSV - Respiratory syncytial virus crackles +/- wheeze Nasal stuffiness, tachypnoea, poor feeding rarely fever >38
how do you manage bronchiolitis in infants
Maximal observation
Minimal intervention
what investigations do you do for bronchiolitis
nasopharyngeal aspirin (NPA) oxygen saturations
what medications do not work for bronchiolitis
salbutamol Ipratropium bromide Adrenalin Steroids Antibiotics
what are LTRI characterized by
48 hrs, fever (>38.5oC), SOB, cough, grunting
wheeze make bacterial cause unlikely
Reduced or bronchial breath sounds
what are the key feautres of pneumonia
Signs are focal, ie in one area (LLZ)
Creps
High fever
what is the management of pneumonia
Nothing if symptoms are mild
Oral Amoxycillin first line
Oral Macrolide second choice
Only for iv if vomiting
what is pertussis
whooping cough
vaccination reduces risk and severity
vomiting and colour change
whats empyeama
Complication of pneumonia
Extension of infection into pleural space, pus
Chest pain and very unwell
Antibiotics+/- drainage
what is acute bronchitis
Inflammation of bronchi
Temporary <3 weeks
Cough and sputum
Usually viral
what are some copd exacerbations
Change in colour of sputum Fevers Increased breathlessness Wheeze Cough
how would you treat exacerbations of COPD
Steroids Antibiotics - amoxicillin - doxycycline - co-trimoxazole - clarithromycin \+/- nebulisers
what is pneumonia
Inflammation of lung parenchyma
what is lung consolidation
solidification due to cellular exudate in alveoli leads to impaired gas exchange
what are risk factors of pneumonia
Smoking, alcohol XS Extremes of age Preceding viral illness Pre-existing lung disease Chronic illness Immunocompromised
what are signs of pneumonia
Tachypnoea Tachycardia Reduced expansion Dull percussion Bronchial breathing Crepitations Vocal resonance inc
what are symptoms of pneumonia
Fever, rigors, myalgia
Cough and sputum
Chest pain (pleuritic)
Dyspnoea
what colour of sputum does streptococcus pneumoniae have
rusty brown sputum
when does mycoplasma pneumoniae occur
occurs in 4-5 year cycles epidemics
what bacteria causes pneumonia from alcoholism
klebsiella pneumoniae
what pathogen cause LRTI in COPD
moraxella catarrhalis
what investigations would you carry out for pneumonia in the community
maybe none
CXR
what investigations would you carry out for pneumonia in the hospital
Bloods – serum biochemistry, FBC, CRP Blood cultures CXR Sputum culture, viral throat swab Legionella urinary antigen
what is the main microorganism responsible for pneumonia
Streptococcus Pneumoniae
what microorganisms are typically communtiy aqquired for pneumonia
Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
what microorganisms are typically nosocomial aqquired for pneumonia
Enterobacteria
Staphylococcus aureus
Pseudomonas aerigunosa
Klebsiella pneumoniae
what is pneumonia severity score
CURB 65 confusion blood urea >7 respiratory rate >30/min systol BP <90 dias <60 age >65
what does a CURB 65 score of 0-1 mean
low risk - could be treated in community
what does a CURB 65 score of 2 mean
moderate risk - hospital treatment usually required
what does a CURB 65 score of 3-5 mean
high risk of death and need for ITU
how do you treat curb score 0-1
Amoxicillin
penicillin allergy - Clarithromycin or doxycycline
how do you treat curb score 2
Amoxicillin + clarithromycin (atypicals)
penicillin allergy - Levofloxacin
how do you treat curb score 3-5
Co-amoxiclav + clarithromycin (atypicals
penicillin allergy - Levofloxacin or
co-trimoxazole
what supportive management would you give for pneumonia
Oxygen, fluids (IV or oral)
Antipyretics, NSAIDs
intubation and ventilation
what are the causes of bronchiectasis
Idiopathic Childhood infection CF Ciliary dyskinesia Hypogammaglobulinaemia Allergic Broncho-Pulmonary Aspergillosis
what are signs of bronchiectasis
Chronic productive cough Breathlessness Recurrent LRTI Haemoptysis Finger clubbing Crepitations (coarse) Wheeze
what is bronchiectasis
dilated distal bronchi, sputum in thickened inflammed airways
what microorganism is it likely to be in lung abscess
Staph aureus, pseudomonas, anaerobes
what is an endemic
the constant presence and/or usual
prevalence of a disease or infectious
agent in a population within a
geographic area
what is an epidemic
an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area.
what is an outbreak
carries the same definition of
epidemic, but is often used for a
more limited geographic area
what i a pandemic
an epidemic that has spread over
several countries or continents,
usually affecting a large number of
people
what is corona virus
• ‘Crown like’ Spikes on surfaces
• Enveloped, RNA based
• Zoonotic
beta coronavirus
what proteins are on the viral envelop of COVID
– Spike proteins
– Envelope Proteins
– Membrane proteins
how does covid replicate
virus enters host cell
releases genome
replicates genome and is assembled
how is covid transmitted
cough, sneeze, touch
what is the reproduction number
The number of people acquiring infection from an infected individual
what is the pathophysiology of covid, what r the phases
viral entry and early infection in lungs
host immune response - immune cells and clearance (macrophages and dendritic cells -> cytotoxic T cells)
hyperinflammatory phase - cytokine storm
multiorgan dysfunction
what are symptoms of covid
Rhinorrhoea, General
Malaise, Headache,
Sore Throat, Cough, Fever
x-ray - white patches, alveoli inflammed
how can you prevent covid
Hand washing Social Distancing Mask Wearing Isolation Vaccines
what are the types of mRNA vaccine for covid
Pfizer, moderna
what attenuated virus vaccine is there for covid
AstraZeneca
what is herd immunity
prevention
if most people are vaccinated, virus will stay contained
what are treatments for covid
antipyretics
steroids
supportive therapy
clinical trials
what is the oxygen flow and concentration in nasal cannula
1-6 litres
25-50%
what is the oxygen flow and concentration in simple face mask
5-10 L
40-60%
what is the oxygen flow and concentration in reservoir mask
15 L
60-90%
what is the oxygen flow and concentration in CPAP
15L
100%
what is the oxygen flow and concentration in nasal high flow oxygen
up to 70L
100%
what is the oxygen flow and concentration in venturi mask , for type 2 resp failure
2-15L
24-60%
what is the oxygen flow and concentration in non-invasive ventilation
0-15 L
who are vulnerable groups for TB
- From high prevalence countries
• 70% are non-UK born, most aged between 15 and 44
• HIV positive, Immunosuppressed
• Elderly, Neonates, Diabetics - Homeless, Alcohol dependency, IV drug users
what is mycobacteria
ubiquitous in the soil, water
few species cause TB, non-TB mycobacteria, leprosy
• Non-motile bacillus, very slowly growing
• Aerobic
- a very thick fatty cell wall (resistant)
how is TB spread
airborne
TB bacteria in aerosol droplets in air
requires prolonged close contact
not by shaking hands etc
how is mycobacteria eliminated outdoor
by UV radiation and dilution
how can mycobacterium bovis be transmitted
consumption of unpasteurized infected cows’ milk
what is the immune response to TB in alveoli
- Activated macrophages > epithelioid cells > Langhan’s giant cells
- Accumulation of those cells -> GRANULOMA
- Central caseating necrosis (after progression)
TB primary infection
Mycobacteria spread via lymphatics to draining hilar lymph nodes
Usually no symptoms, can be fever, malaise. Erythema nodosum, rarely chest signs
tg
what is the primary complex of TB and ghon focus + complex
Initial lesion + local lymph node
heals with/without scar, may calcify
what are the outcomes of primary infection of TB
progressive disease
contained latent
cleared cured
what can primary infection of TB progress to
Tuberculous bronchopneumonia
cavitation
Enlarged hilar lymph compress bronchi, lobar collapse
Enlarged lymph node discharges into bronchus
what can miliary TB progress to
hematogenous spread of bacteria to multiple organs
what is post primary disease of TB
1) TB in dormant stage w low/no replication over prolonged periods of time
2) balance of replication + destruction by immune mechanisms
what are the presentations of TB
cough
fever
sweats (night)
weight loss
how do you diagnose active TB
CXR
apices soft, fluffy
how do you diagnose active pulmonary TB
CXR
Mediastinal lymphadenopathy
• Pleural effusion
• Miliary
how do you sample TB microorganism
sputum sample
bronchoscopy with BAL
endobronchial US w biopsy
lumbar puncture in CNS TB
what is the clinical management of TB
Isoniazid (H)
Pyrazinamide (Z)
Rifampicin (R)
Ethambutol (E)
multi drug therapy essential
what are the side effect of Isoniazid (H)
can cause polyneuropathy
Vitamin B6 to prevent
hepatitis
what are the side effect of Rifampicin (R)
reduce effectiveness of oral contraceptive pill
hepatitis
induces liver enzymes
what are the side effect of Ethambutol (E)
vision monitored can cause optic neuritis
what is the standard treatment for TB
2 R/H/Z/E + 4 R/H
what are the side effect of Pyrazinamide (Z)
Hepatitis
Gout
what is the treatment of latent TB
Rifampicin & Isoniazid for three months, or
• Isoniazid/rifampicin only for six months, or
• Rifapentine & Isoniazide once weekly for 12 weeks
lung cancer is most common cause of cancer related death
ggd
what is the aetiology for lung cancer
TOBACCO Asbestos Environmental radon Air pollution and Urban environment Other radiation Pulmonary fibrosis
how does smoking affect risk of lung cancer in m and f
males - inc 22times
f - 12times
f more susceptible
what are 2 main pathways of carcinogenesis in the lung
In the lung periphery -> adenocarcinoma
in central lung airways -> squamous cell carcinoma
what are non-small cell carcinomas
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinomas
Others
primary lung cancer, grow clinically silent for years, v few signs/symptoms
gg
what are local effects of lung cancer
Bronchial Obstruction : Collapse Endogenous Lipoid Pneumonia Infection / Abscess Bronchiectasis
pleural - inflammatory, malignant
direct invasion - chest wall
lymph node metastases
what effect can you get if lung cancer invades phrenic nerve
diaphragmatic paralysis
what effect can you get if lung cancer invades Recurrent laryngeal nerve
Hoarse, Bovine cough
what effect can you get if lung cancer invades Brachial plexus
Pancoast T1 damage
what effect can you get if lung cancer invades Cervical Sympathetic
Horner’s syndrome
where can lung cancer metastases to distantly
Liver, Adrenals, Bone, Brain, Skin
what are some non-metastatic effects of lung cancer
Finger clubbing and
Hypertrophic Pulmonary
Osteoarthropathy
what investigations would you do for lung cancer
Chest X-Ray
Sputum Cytology rarely used
Bronchoscopy
Pleural effusion cytology and Biopsy
CT, MRI, PET
what is the 5 year survival of non-small cell carcinoma
Anywhere between 10-25%
what is the 5 year survival rate of small cell carcinoma
4%
Median survival 9 months
what biomarkers can be used for predictive therapy in adenocarcinomas
EGFR, KRAS, HER2, BRAF mutations,
ALK translocations, ROS1 translocations etc
what are the symptoms of lung cancer
chronic coughing > 3 weeks coughing blood wheeze chest +bone pain SOB weight loss nail clubbing
what are the symptoms of metastatic lung cancer
• Bone pain
• Spinal cord compression
– Limb weakness
Cerebral metastases
– Headache
• Thrombosis
what are the symptoms of paraneoplastic lung cancer
Hyponatraemia
Anaemia
Hypercalcaemia
what are the clinical signs of lung cancer
- Chest signs • Clubbing • Lymphadenopathy • Horner’s syndrome • Pancoast tumour • Superior vena cava obstruction • Lymphadenopathy
what investigations would you do for lung cancer at the GP
CXR • FBC • Renal, Liver functions and Calcium • Clotting screen • Spirometry
what investigation would you use to stage lung cancer
CT of thorax + abdomen
PET scan
what investigations for lung cancer for tissue diagnosis
- Bronchoscopy • EBUS endobronchial US • Image guided lung biopsy • Image guided liver biopsy • Excision of cerebral metastasis! • Bone biopsy • Mediastinoscopy/otomy • Surgical excision biopsy
what do you use for staging lung cancer
T - tumour size, spread, position
N - spread to l nodes?
M - metastases
how many stages does lung cancer have
1-4
4 has worst survival
what are the two treatment types for lung cancer
radical or palliative
what is the performative status
- 0 = fully active
- 1 = symptoms but ambulatory
- 2 = “up and about” > 50%, unable to work
- 3 = “up and about” < 50%, limited self care
- 4 = bed or chair bound
what treatments are there for lung cancer
surgery
radiotherapy
chemotherapy
supportive care
what is included in palliative management in lung cancer
symptom control
- chemotherapy, radiotherapy, opiates
QoL
community support
what investigation do you do for systematic review of lung cancer
CXR
Hilar vascular structures crisply defined
No widening of mediastinum
Trachea should be central
look at lungs upper, middle, lower zone
look behind heart and diaphragm
what do you look for in CT for lung cancer
evaluate size, shape atelectasis, border, density ,solid or non solid, dynamic contrast enhancement >25 HU, growth
what is a pulmonary mass
opacity in lung over 3cm with no mediastinal adenopathy or atelectasis (collapse)
what is a pulmonary nodule
opacity in lung up to 3cm with no mediastinal adenopathy or atelectasis (collapse)
what things do you use to stage lung cancer
Clinical history/examination
Performance status
Pulmonary function
TNM
what is T1 of TNM
Tumour ≤3 cm
what is T2 of TNM
Tumour >3 cm but 5 cm
what is T3 of TNM
Tumour >5 cm but <7cm
invades chest wall, phrenic nerve, parietal pericardium
what is T4 of TNM
Tumour >7cm
invades diaphragm, mediastinum, heart
what may you see in a CXR for staging of lung cancer
Pleural effusion
Chest wall invasion
Phrenic nerve palsy
Collapsed lobe or lung
what may you see in a blood tests for staging of lung cancer
Anaemia
Abnormal LFTs (liver function)
Abnormal bone profile
what may you see in a CT for staging of lung cancer
Size of tumour Mediastinal nodes Metastatic disease - other parts of lungs, liver, adrenals, kidneys Proximity to mediastinal structures Pleural/pericardial effusion Diaphragmatic involvement
what other tests can you do for staging of lung cancer
PET
MRI
Bone scan
ECHO
what pathologies do you need to check for when assessing patients fitness for lung cancer surgery
angina, heart problems, smoking, stroke, asthma, URTI, exercise capacity
what are some respiratory function tests to check fitness for lung cancer surgery
Spirometry
Diffusion studies
ABG on air/SLV
Fractionated V/Q scan
what are some cardiac assessments to check fitness for lung cancer surgery
ECG ECHO CT scan ETT Coronary angiogram If in doubt, don’t operate
what is the aim of surgical treatment for lung cancer
Curative resection
Remove the minimum amount of lung tissue
Resection of parietal structures is feasible
what types of surgery are there for lung cancer
Pneumonectomy 5-10%
Lobectomy 3-5%
Wedge resection 2-3%
Open/ close thoracotomy 5%
(operative mortality)
what are non-small cell lung cancers
85% of lung cancer Adenocarcinoma - 55% Squamous – 30% Large cell undifferentiated ~5% Others
By what percent does a PET scan upstage lung cancer
15%
what percent of non-small cell lung cancers are operable
25%
what adjuvant therapy may you give post-operatively after lung cancer surgery
Chemotherapy - to increase chance of cure/reduce risk of recurrence
no radiotherapy for stage 1 and 2
what are the side effects of radical radiotherapy
lethargy
Acute: oesophagitis, pneumonitis, dysphagia
Long term: pulmonary fibrosis, oesophageal stricture, cardiac
Pulmonary function tests essential for radical RT
ffd
Radiotherapy is planned and there are variety of regimes
fff
what is chemotherapy
systemic treatment
survival better than RT alone
addition increases toxicity
what are side effect of chemotherapy
it increases toxicity Nausea, GI upset, marrow suppression (Neutropaenic sepsis) and risk of life threatening infection hair loss neuropathy
what is Stereotactic Ablative Radiotherapy (SABR)
can give high doses or in fractions
Can have similar outcomes to surgery
Tumours up to 4 cm
>2cm away from airways and proximal bronchial tree
when would you offer palliative treatment for lung cancer
80% of patients with disease that is not curable
Stage IV – distant metastasis
Stage III – very locally advanced disease
also affected by co-morbid disease eg. angina, COAD
what does palliative treatment include for lung cancer
Chemotherapy Immunotherapy TKI Palliative radiotherapy Combination of above
what is palliative immunotherapy
works by upregulating immune system and ‘unmasking’ cancers
what are palliative tyrosine kinase inhibitors
Targeted drugs for adenocarcinoma with driver mutation
shrinks tumour
what is palliative radiotherapy
For Management of symptoms:
Bone metastasis
Cord compression
Haemoptysis
what is the doubling time of small cell lung cancer
29 days
what is small cell lung cancer staged as
Limited disease – confined to one hemithorax
Extensive disease – more advanced
for limited small cell lung cancer what treatment may you give
ChemoRT curative treatment
Followed by prophylactic cranial radiation (PCI)
combo of drugs
for limited small cell lung cancer what treatment has no benefit
High dose chemo
Alternating chemo
Maintenance chemo
for extensive small cell lung cancer what treatment may you give
4 cycles only of combination chemotherapy
Consolidation thoracic RT
prophylactic cranial radiation (PCI)
describe the pleura
smooth, thin membrane which covers the thoracic cavity and the lung
Outer layer : Parietal Pleura
Inner Layer : Visceral Pleura
In between : Pleural fluid
what is the protein content in pleural fluid
1.5-2g/dl
what is pleural effusion
Collection of fluid in the pleural space
Imbalance between production and absorption
what are the types of pleural effusion
transudate - non-inflam
exudate - inflam, protein content 3g or more
what is transudate
is non-inflam pleural effusion
what is exudate
is inflammatory pleural effusion
protein content 3g or more
what is the lights criteria
Protein : Pleural fluid /serum fluid ratio > 0.5
LDH : Pleural fluid /serum fluid ratio > 0.6
Pleural fluid LDH > 2/3 rd ULN serum LDH
in lights criteria what is the ratio of protein in pleural fluid/serum
> 0.5
in lights criteria what is the ratio of LDH in pleural fluid/serum
> 0.6
what are the causes of transudate pleural effusions
Left ventricular failure
Liver cirrhosis
mitral stenosis
what are the causes of exudate pleural effusions
Malignancy ( Pulmonary and non pulmonary)
Parapneumonic effusions, empyema
Tuberculosis
what investigations do you do for pleural effusions
US, mark site for aspiration, assess pleura
CXR
CT thorax, for complex effusions, visualise pleura and structures
what analysis do you do of pleural fluid
pH, biochemistry, microbio and cytology
how do you manage pleural effusions with pH <7.2
PH less than 7.2 with pneumonia, pus or blood may need a chest drain
how do you treat transudate pleural effusion
treat the underlying cause
how do you treat exudate pleural effusion
Unless cause identified will need further investigation e.g. further imaging , and or pleural biopsy
what is a pneumothorax
collection of air within pleural space
chest pain/breathlessness
what would you see on examination for pneumothorax
Breathing fast
Hypoxic
Reduced chest wall movement and reduced or no breath sounds
how do you diagnose pneumothorax
CXR
US
CT thorax
how do you manage pneumothorax
observe
aspiration, >2cm in size take air out
chest drain insertion, safe triangle 2nd ICS midclavicular
surgery
what primary malignancy is most common in pleural tumours
mesothelioma
what is mesothelioma
pleural tumour
rare, aggressive
inhaled asbestos fibres reach pleura -> inflammation -> tumour formation
what are the signs of mesthothelioma
Breathlessness
Chest Pain
Weight loss
Clubbed , signs of a pleural effusion
how do you diagnose mesothelioma
CXR
CT thorax and biopsy
thickened pleura, pleural plaques, effusion
how do you treat mesothelioma
treat effusion
chemotherapy
palliative surgery
how many carcinogens are in cigarette smoke what does it do to immune cells
60
suppresses T cell function
how many deaths a year are due to smoking
10,000
1/5 of deaths
in deprived areas how much more likely are you to smoke
3 times
what are the effects of maternal smoking
350g lighter birth weight
double likelihood of still birth
after 15 years of quitting smoking your risk of heart attack is the same as someone who never smoked
ggg
how does smoking affect the NHS and society
nhs - copd, lung cancer, cardiac diseases
spciety - loss of productivity/economic output, fires, passive smoking effect
what strategies are there to protect children from smoking
X sell tobacco products to anyone < 18
X smoke in private vehicle with kids in it
X proxy purchase
X vending machines
what strategies are there to reduce smoking in public
Banned in virtually all public places and workplaces
how does packaging of cigarettes reduce smoking
65% of pack must be covered with picture warnings
ban on flavours
minimum pack size 20
describe normal airflow in airways
Bulk flow – laminar or turbulent
Depends on pressure difference
what are 4 types of abnormal pulmonary gas exchange
Ventilation / Perfusion imbalance - V/Q - airway obstruction
Diffusion impairment - loss of alveolar surface area, thickened interstitium
Alveolar Hypoventilation - red respiratory drive
Shunt
what is normal V/Q and what causes low V/Q
Normally breathing ~4 l/min. Cardiac Output is ~5 l/min so normal V/Q is 4/5 or 0.8
low due to local alveolar hypoventilation
what is shunt
Blood passing from Right to Left side of Heart WITHOUT contacting ventilated alveoli
Pathological shunt in AV malformations, congenital heart disease and PULMONARY DISEASE
do large shunts respond well to inc in FI O2
no
what is alveolar hypoventilation
ventilation - air moved in and out lungs
less air
PaCO2 inc
PaO2 decrease
what is restrictive lung disease
forced vital capacity is <80% normal
but FEV1/FV ratio is normal
what causes restriction of lung
lungs, pleura, nerve/muscle, bone
what are some restrictive lung disease
interstitial lung disease
idiopathic pulmonary fibrosis
sarcoidosis
hypersensitivity pneumonitis
how does pleura cause restrictive lung disease
effusions (fluid)
pneumothorax
thickening of pleura
how does skeletal cause restrictive lung disease
kyphoscoliosis
rib fractures
ankolysing spondylitis
how does muscle/nerve cause restrictive lung disease
amyotrophic lateral sclerosis
how do sub-diaphragmatic cause restrictive lung disease
obesity, pregnancy
where is the interstitium
between alveolus and capillary wall
what are interstitial lung disease
cause thickening of interstitium and can result in pulmonary fibrosis
what is Obstructive Sleep Apnoea Syndrome?
Recurrent episodes of upper airway obstruction leading to apnoea (cessation of breathing) during sleep and waking up
impaired QoL
what is the pathophysiology of sleep apnoea
muscle relaxation
narrow pharynx
obesity
= repeated closure of upper airway
how is sleep apnoea diagnosed
Clinical history and examination Epworth Questionnaire Overnight sleep study -pulse oximetry -limited sleep studies -full polysomnography
what conditions are associated with sleep apnoea
hypertension, increased risk of stroke and probably increased risk of heart disease.
how do you treat sleep apnoea
Identify exacerbating factors - weight - alcohol Continuous positive airways pressure (CPAP) Mandibular repositioning splint
what is narcolepsy
neurological condition that affects the brain’s ability to regulate the normal sleep-wake cycle, wake up and sleep at inappropriate times
what are clinical features of narcolepsy
Cataplexy - sudden muscular weakness
Excessive daytime sleepiness
Hypnagogic / hynopompic hallucinations
Sleep paralysis
what investigations do you do for narcolepsy
Polysomnography PSG
MSLT (>1 SOREM and mean sleep latency <8 min). measure time to fall asleep
Low CSF orexin
how do you treat narcolepsy
Modafinil
Dexamphetamine
Venlafaxine (for cataplexy)
Sodium Oxybate (Xyrem)
what are features of chronic ventilatory failure
Elevated pCO2 (> 6.0 kPA)
pO2 < 8 kPA
Normal blood pH
Elevated bicarbonate (HCO3-)
what is the aetiology of chronic ventilatory failure
Airways disease
-COPD
-bronchiectasis
Chest wall abnormalities
Respiratory muscle weakness
Central hypoventilation
what are symptoms of chronic ventilatory failure
Breathlessness Orthopnoea Ankle swelling Morning headache Recurrent chest infections Disturbed sleep
what would you find on examination for chronic ventilatory failure
paradoxical abdominal wall motion in suspected neuromuscular disease
Ankle oedema
what treatment do you give for chronic ventilatory failure
Domicillary Non Invasive Ventilation (NIV)
Oxygen therapy
what are the stages of lung development
embryonic 3-8 weeks pseudoglandular 5-17 canalicular 16-26 saccular 24-38 alveolar 36 to 2/3yrs
what happens in embryonic stage of lung development
lung buds form - lobar buds
what happens in pseudoglandular stage of lung development
rapid branching of airways, specialised cell devlopment
what happens in canalicular stage of lung development
lung develop distal architecture, terminal bronchiole, alveolar sacs, capillary units
Type 1 and 2 pneumocytes
point of viability
what happens in saccular stage of lung development
alveoli grow, surfactant produced
can have gas diffusion now
what happens in postnatal lung growth
Alveolar septation continue after birth
what are common upper resp congenital abnormailities
Laryngomalacia and Tracheomalacia
Tracheo-oesphageal fistula ( abnormal connection)
what are common lower resp congenital abnormailities
CPAM pulmonary artery malformation
Congenital Diaphragmatic Hernia
how do you diagnose congenital abnormalities antenatally
Ultrasound
MRI
how do you diagnose congenital abnormalities postnatally, what signs are there
Tachypnoea
Respiratory distress
Feeding issues
what is Laryngomalacia
softening/collapse of larynx, obstructed airway
- stridor
what is Tracheomalacia
floppiness of trachea
barking cough
genetic condition associated
what happens with the lungs when the child is born
after first breath lungs inflate and fluid in lungs is absorbed
what is Respiratory Distress Syndrome and what is it due to
Neonatal Lung Disease
Due to surfactant deficiency
how do you treat Respiratory Distress Syndrome
Antenatal steroids
Surfactant replacement
Appropriate ventilation and nutrition
what factors affect lung function, ‘tracking’ of lung function from early life to adulthood
individual - sex, age
early life events - parental education, season of birth, birth weight
environment and lifestyle - air pollution, smoking
allergic diseases - asthma. food allergen
what is remodelling
Alteration of airway structure following external influence
-Environmental exposures
-Chronic diseases of childhood
-Infection
Leads to abnormalities due to interference of inter-cellular signalling
what are the genetics of cystic fibrosis
autosomal recessive
occurs when 2 mutated genes inherited from both parents
how does cystic fibrosis occur
occurs due to mutation in the transmembrane conductance regulator protein (CFTR) which is coded on chromosome 7
Cl trapped in cell, Na and water stay in cell too
Dehydrates airway surface liquid and mucous layer
Thick mucous sticks to mucosal surface, causing shearing
Difficult to cough up
Mucous collects bacteria, reduced ability to fight infection
what protein is mutated in cystic fibrosis and on what chromosome
transmembrane conductance regulator protein (CFTR)
chromosome 7
what are the different classes of mutation for the CFTR protein (cystic fibrosis)
1-6
1-3 severe diseases
4-6 milder
how do you diagnose cystic fibrosis antenatally
Pre-implantation genetic diagnosis
Chorionic villous sampling (from placenta)
Amniocentesis (amniotic fluid tested)
how do you diagnose cystic fibrosis neonatally
Newborn bloodspot day 5
(Guthrie test)
then clinical assessment and sweat test
what is sweat testing
Measures the concentration of chloride excreted in sweat.
Elevated in CF
what are some presentations of CF
Pancreatic insufficiency
Diabetes
Chest Infections and Bronchiectasis
how does CFTR cause pulmonary infection
Abnormal electrolyte transport across cell membrane
Dehydration of airway surface layer
dec mucociliary clearance
Mucous sticks to mucosal surface and causes shearing and inflammation
inc access to bacteria
dec bacteria killing
how does progressive respiratory decline occur in cystic fibrosis
Progressive bronchiectasis: chronic sputum production
recurrent chest infections
progressive airflow obstruction
can lead to respiratory failure
how do you treat pancreatic insufficiency in CF
- REPLACE ENZYMES: (CREON)
- DIET: High energy plus high calorie supplement drinks
- NUTRITIONAL SUPPLEMENTS: Fat-soluble vitamin and mineral supplements
how do you treat mucous obstruction inflammation in CF
Airway clearance
via physiotherapy,
Mucolytics
Bronchodilators
how do you treat chronic infection in CF
Antibiotics (oral,
Intravenous or
Nebulised)
how do you treat inc inflammation in CF
Azithromycin
how do you treat Fibrosis/scarring/bronchiectasis in CF
Supportive treatment
and management of symptoms
what type of diabetes can you get in CF
TYPE 2 DIABETES MELLITUS
Not enough insulin from pancreas, or insulin is not working properly
how do you get osteoporosis in CF
Bone mineral density (BMD) falls
may get haemoptysis, pneumothorax, diabetes and osteoporosis in CF
fsfs
how does CF affect children socially
barrier to making friends
increased cost to family
inc depression/anxiety
how does CF affect adults socially
transition
restriction on careers and hobbies
transport costs
missing work
what microrganism is most common in infection in CF in adults
Pseudomonas Aeroginosa
what are the indications for lung transplant
Rapidly deteriorating lung function
FEV1 < 30% predicted
Life threatening exacerbations
Estimated survival <2 years
Other: recurrent pneumothorax, recurrent severe haemoptysis
what things can be considered to improve qol in CF
Oxygen and NIV
Exercise
Support – physical, mental, social, financial, . Alternative therapies (massage, reflexology, exercise equipment, gym memberships)
Advanced Care plans
what can cause empyema
Post pneumonic
Post-operative
Oesophageal
Upper abdominal related
what surgery can be done to treat empyema
Pleurectomy & Decortication
what Thymic tumours can you get
Thymoma Thymolipoma Thymic carcinoma Carcinoid tumours of the thymus Lymphoma
when would you do tracheal surgery
Repair of iatrogenic injury
Tracheal tumours
-Salivary gland tumours
-Squamous carcinoma
what are some benign lung tumours
Hamartoma Fibroma Lipoma Neural tumours Papillomas
what the difference between primary and secondary pneumothorax
primary - occurs without an apparent cause and in the absence of significant lung disease
secondary - preexisting lung disease
what is a spontaneous haemopneumothorax
after recurrent pneumothorax’s
adhesion forms between lung and chest wall
torn in pneumothorax -> bleed
what is bullous lung disease
abnormal airspace in lung > 2cm
Indications for Surgery in Pneumothorax
Recurrence
Persistence
Sometimes after one episode
what Surgery is there for pneumothorax
Pleurodesis
Pleurectomy
what are Bronchogenic Cysts
Cause symptoms by pressing on the trachea or oesophagus
what are the requirements for lung transplantation
Age < 65 years Not overweight Not diabetic No renal failure No mental illness Good social support
what is a pulmonary embolism
Thrombus forms in the venous system, usually in deep veins of the legs and embolises to the pulmonary arteries.
what are major risk factors for Venous Thromboembolism
Recent major trauma Recent surgery Cancer Significant cardiopulmonary disease e.g. MI Pregnancy
what are the symptoms of pulmonary embolism (PE)
- Pleuritic chest pain, cough and haemoptysis
- Isolated acute dyspnoea
- Syncope or cardiac arrest (massive PE)
what are the signs of PE
- Pyrexia, pleural rub, stony dullness to percussion at base (pleural effusion)
- Tachycardia, tachypnoea, hypoxia
- Tachycardia, hypotension, tachypnoea, hypoxia
what pre- test probability can you do for pulmonary embolisms
Wells Score
Includes symptoms and signs of VTE, previous VTE and risk factors
Revised Geneva Score
Based on risk factors, symptoms and signs
what investigations for PE
Full blood count, biochemistry, TnI, blood gases Chest X-Ray ECG D-dimer CT Pulmonary Angiogram (CTPA) V/Q scan Echocardiography
what treatment for PE
Oxygen Low molecular weight heparin e.g. dalteparin Warfarin Direct Oral Anticoagulants (DOAC) rivaroxaban, apixaban Thrombolysis Alteplase (rt-PA) Pulmonary Embolectomy
what is pulmonary hypertension
Elevated blood pressure in the pulmonary arterial tree.
mean pulmonary artery pressure of > 25 mmHg.
what are the causes of pulmonary hypertension
Idiopathic (group 1)
Secondary to left heart disease (2)
Secondary to chronic respiratory disease (3)
Chronic Thromboembolic PH (CTEPH) (4)
what are the symptoms of pulmonary hypertension
Exertional dyspnoea
Chest tightness
Exertional presyncope or syncope
Haemoptysis
what are the signs of pulmonary hypertension
Elevated JVP Right ventricular heave Loud pulmonary second heart sound Hepatomegaly Ankle oedema
what investigations for pulmonary hypertension
ECG Lung function tests Chest X-Ray Echocardiography V/Q scan CTPA Right heart catheterisation - direct measure of pulmonary artery pressure
what is the general treatment for pulmonary hypertension
Treat underlying condition
Oxygen
Anticoagulation
Diuretics
what specific treatment is there for pulmonary hypertension
Calcium channel antagonists
Prostaglandins e.g. iloprost
Prostacyclin agonist
Endothelin receptor antagonists
what surgical treatments are there for pulmonary hypertension
Thromboendarterectomy
Lung or heart lung transplant
